Review Article, Int J Ment Health Psychiatry Vol: 5 Issue: 1

Obsessional Compulsive Disorder (Waswâs al-Qahri (Overwhelming Whisperings): Case Report and Spiritual Interventions

Rassool GH^*

Sidi Bou Said II, 19 Mamodeally Lane, Morcellement Balgobin, Rose Hill-71327, Mauritius

*Corresponding Author : Rassool GH
Sidi Bou Said II, 19 Mamodeally Lane, Morcellement Balgobin, Rose Hill-71327, Mauritius
E-mail: husseinrassool@gmail.com

Received: May 20, 2019 Accepted: July 10, 2019 Published: July 17, 2019

Citation: Rassool GH (2019) Obsessional Compulsive Disorder (Waswâs al-Qahri (Overwhelming Whisperings): Case Report and Spiritual Interventions. Int J Ment Health Psychiatry 5:1.

Abstract

Keywords: Obsessive-compulsive disorder; Psycho-behavioural

Introduction

Religion or religious beliefs have often been thought to play a part in the genesis of some cases of obsessive-compulsive disorder (OCD). Obsessive-compulsive disorders related to religiosity and are referred in the literature as Scrupulosity.

Pollard stated that Scrupulosity is a form of Obsessive Compulsive Disorder involving religious or moral obsessions. Scrupulous individuals are overly concerned that something they thought or did might be a sin or other violation of religious or moral doctrine [1]. Rassool suggested that this psycho-behavioural disorder involves pathological guilt about moral or religious issues or fears supplemented with mental or behavioural compulsions which affect individuals of various religions across the world [2]. All forms of OCD cause the individual to experience the same obsessional and compulsive cycle including obsession, anxiety and compulsion which cause the individual to be in loss of control and dysfunctional. The fear of sin and fear of God have been identified as the key dimensions of Scrupulosity OCD. In Scrupulosity OCD, these obsessional thoughts involve intrusive religious blasphemous thoughts, compulsive prayer, hyper-morality, unwarranted concern about committing a sin and cleaning/washing rituals [3]. In Scrupulosity OCD the individual is overpowered by religious obsessions which can lead to compulsive religious practices and rituals.

In Islam, the devil is called Shaytan (Satan) and Iblees is one of the Jinn. Everything that happens among the believers and non-believers is the whispering of Satan, as an obsessive whisperer, to prevent people from the remembrance of God. Al-Bakhi stated that the origin of this obsessive disorder from the devil appointed to a person (The Qareen) that strives to spoil one’s life in this world [4]. It has been suggested that there are three types of obsessives according to the Islamic understanding: self-talk, which relates to pleasure, self-love, wishes, and desires, irrespective of whether it is halal or forbidden; Second: the whispers of Satan, the obsessive whisperer, who is the enemy of man in command of his religion; and finally OCD is the most important characteristic that is contrary to the nature of the individual and it is not sufficient to seek refuge with Allah from Satan to get rid of those obsessions [5]. In Islam, such unwanted thoughts are called Waswâs (plural of Waswâsah) which is the whispering of the devil or the devil's insufflations (Waswâs-il-Khannas) [6], over and over again, as Waswâsah by itself suggests repetition. The OCD-Scrupulosity from an Islamic perspective, is categorised as Waswâs al-Qahri. This typology is akin to pathological obsessive-compulsive disorder (OCD) but the diagnosis is not included in the Diagnostic Statistical Manual (DSMV) [7] or the International Statistical Classification of Diseases and Related Health Problems (ICD-10) [8]. Although Waswâs al-Qahri this overwhelming whisperings are common to Muslim believers but for some, it becomes an obsession and compulsion. Waswâs al-Qahri including obsession related with belief, performing rituals, purification and obsession related to cognitive and affective experiences of losing control of one’s life. Waswâs al-Qahri including obsession related with belief, performing rituals, purification and obsession related to cognitive and affective experiences of losing control of one’s life. This paper examines the different types and sources Waswâs al-Qahri including obsession related to belief, performing rituals, purification and obsession related to cognitive and affective experiences of losing control of one ’ s life. A case report is presented with spiritual interventions.

Sources of Waswâs al-Qahri

Waswâs al-Qahri (In Arabic overwhelming whisperings) is a manifestation of some kind of obsessive-compulsive disorder commonly expressed in Muslim populations that involve anxiety, phobic anxiety, cognitive distortions, personality disorders and obsessional neurosis. Awad described Waswâs al-Qahri as consisting of intrusive thoughts that cause cognitive dissonance (mental distress due to contradictory beliefs, values, or thoughts), and poses a risk to a person’s spiritual and psychological homeostasis [9]. The condition of Waswâs al-Qahri has been described as a sickness which befalls some people like any other kind of sickness. It refers to repeated thoughts, movements, ideas or notions which are of a loathsome nature that a person would ordinarily reject and strive to resist. He also realised that they are wrong and have no meaning, but there is something that is pushing him towards them and he usually fails to resist them. The strength of these Waswâs may vary, so much so that they appear – to non-specialists – to be very strong and it seems that the sick person is doing that willingly. This kind of Waswâs may also affect a person in his worship and in his worldly affairs [10]. There are three sources of Waswâs derived from the Nafs (or self, ego, soul), which is inclined to evil, the devils among the Jinn (demons), and the devils among mankind. Nafs, in this context, refers to the lower self, similar to the ego, in that it is part of the soul that inclines towards the Dunya through desires, distracting a person from Allah and opening them to the influence of Shaytan (the devil) [11].

The first source of Waswâs is from the Nafs al-Ammara Bissu' (The Soul which Commands). This means we are controlled by this Nafs who directed us to follow its dictates and commands. The appetite of this kind of Nafs leads us to commit unacceptable behaviours and sins.

According to Utz, the intrusive thoughts are from the Nafs itself, which may be inclined to evil [12]. This kind of Nafs, by its intrinsic nature nudges human beings into evil actions. It is stated in the Noble Qur’an (Interpretation of the meaning) “that the soul is a persistent enjoiner of evil [13]. We have already created man and know what his soul whispers to him [14]. The second source of Waswâs is the devils among the Jinn. It is stated in the Noble Qur’an (Interpretation of the meaning). Then Satan whispered to him [15]. According to Rassool, this Waswâs “ entices an individual to do something against the teaching of his religious beliefs and practices. Furthermore, it instils doubt within a believer about his faith [2]. The third source comes from the Jinn or from human beings. This is illustrated in the Qur’anic verses, From the evil of the retreating whisperer; Who whispers (evil) into the breasts of mankind; From among the Jinn and mankind [16]. That is, according to Ibn al-Qayyim, a major difference between Waswâs that comes from Shaytan and Waswâs from the Nafs is that Waswâs from the Nafs it is what urges the person to commit a specific sin and repeatedly seeks to make him do it [17]. Whereas the one from Shaytan is that the Waswâs that comes from the Shaytan makes sin appear attractive until the Muslim falls into it; if the Shaytan is unable to achieve that, he moves on to another sin, and if that does not work he moves on to a third, and so on. Another difference between Waswâs that comes from Shaytan and Waswâs from the Nafs is that Waswâs from the Nafs is what urges the person to commit a specific sin and repeatedly seeks to make him do it. Whereas, the Waswâs that comes from the Shaytan makes sin appear attractive until the Muslim falls into it; if the Shaytan is unable to achieve that, he moves on to another sin, and if that does not work he moves on to a third, and so on [18].

Typology of Waswâs al-Qahri

An understanding of the typology of Waswâs al-Qahri indicates that the disorder can manifest itself, in clinical setting, in many different ways. Abdullah identified two types of Waswâs: Type I and Type II depending on severity of the conditions [19]. Type I is the most common and less severe one that everyone are susceptible to. The characteristics include whispers, occurring negative fleeting thoughts and feelings that does not interfere in the daily normal and spiritual activities of the individual. Type II is the severe Waswâs al-Qahri is more severe and debilitating with a gradual onset and closely related to OCD-Scrupulosity. Awad [9] identified three categories and Rassool [2] added another category of Waswâs al-Qahri identified in clinical settings:

Waswâs al-Qahri Fee Aqeedah (belief).

Waswâs al-Qahri Fee Ibadah (worship),

Waswâs al-Qahri Fee Taharah (purification).

Waswâs al-Qahri Fee Kwaf Min Fuqdan al Saytara (fear of losing control).

It is beyond the scope of this paper to examine the characteristics of Waswâs al-Qahri. A summary of the typology, obsessions and compulsions of Waswâs al-Qahri is presented in Table 1.

Table 1: Summary of the Typology, Obsessions and Compulsions of Waswâs al-Qahri.
Source: Adapted from Rassool, G. Hussein (2018) Evil Eye, Jinn Possession and Mental Health Issues: An Islamic Perspective. Oxford: Routledge.

Diagnosis of Waswâs al-Qahri

There are many Muslims that experienced the Type I Waswâs al- Qahri, including doubts, uncertainty, disturbing thoughts and reflections in their normal life and in particular during the acts of worship, ablution and purification. However, although these causes constant ordeal of irritation, stress and confusion, there are not regarded as pathological. Currently there is no defined, formal criteria for the diagnosis of Waswâs al-Qahri but experienced Imam and those who treat Waswâs al-Qahri with spiritual interventions who be able to identify this condition.

Awad suggested that the “informal diagnosing generally happens when a person is distressed or shows impairment due to irrational fears about aspects of the religion; (ii) for a significant period of time and; (iii) behaves in maladaptive ways (excessively repeating acts of worship, checking, ruminating, etc.)[9]. Rassool suggested criteria for diagnosing Waswâs al-Qahri include the following criteria:

Recurrent, intrusive and persistent thoughts that cause marked anxiety or distress;

Symptoms are persistent for a significant period of time;

Excessive fear of having acted counter to one’s personal values and morals;

Impairment due to irrational fears about aspects of the religion;

Inordinate focus on moral and religious perfection;

Overt behavioural compulsions;

Use maladaptive coping mechanisms (excessively repeating acts of worship, checking, ruminating, etc.);

Ritualised ‘undoing’ behaviours to counteract perceived sins and transgressions;

Avoidance behaviours;

Beyond enhanced religious practices [2].

Case

S is 26-year old divorced woman reporting a history of recent change in personality with dissociative state, impairment of sensory perception, somatoform and physical disorders. The changes in behaviour started when she got engaged when she was 19 years of age. The patient complained of abnormal auditory experiences when alone. She previously worked as a school teacher for four years and then trained as a pharmacist dispenser. She complained of never feeling alone in the house as there was always someone out there. At times, she felt that her husband was there but when she looked all over the house, there was neither presence of her husband nor any other member of the family. She reported having seen images of dolls in front of her but disappeared afterwards. Other bizarre experiences include the sound of utensils falling down on the marble floor, hearing laughing, and voices that make enough noise to prevent her from resting during the day. She reported of suffering “block head”, severe cramps, rigidity of both feet, bad smell from her mouth and a rigid tongue. When she started to read the Qur’an, she felt severe pain between her thumb and index. S also complained of bad dreams and nightmares. In addition, she had fear of contamination during ablution and bathing, and developed compulsions related to worship and purification. According to the patient's mother, S. had become isolated, disinterested and withdrawn, and in constant conflict with her. There is no history of psychiatric illness in the family.

Below are some of the problems of obsessional behaviours related to different typology of Waswâs al-Qahri. The following is the verbatim statements made by S.

Everything started bit by bit: fear of contamination of clothing, fear of contamination during and after ablution (Wudu), overwhelming whisperings or obsessional thoughts during prayer; and having thought block.

Waswâs al-Qahri Fee Taharah, obsession related to purification

This is the fear of contamination of clothing. When I come out of the toilet my thoughts are telling me that soiled water may have splashed on my clothing. And I also feel that soiled water have splashed on my feet. With these contaminated clothing, I cannot do my daily prayers. When I returned home after going out, I put all my clothing in the laundry basket because they are contaminated. I am aware of the rulings and punishment that one needs to be cleansed of all impurities before praying. I either put the ‘dirt’ clothing for washing or wash them thoroughly. After washing the clothing, I needed to take a bath because of the fear of having dirty water splashing on my body. If I hold the door handle of the bathroom, I washed both the doors handle of the bathroom and toilet with water. In one day, I would change my clothes about 7 times or more and even put all my ‘clean’ clothing in the wardrobe for washing.

Fear of contamination during Ablution and Ghusl

Ablution (Wuḍ�?«�?¾) is the Islamic procedure for washing parts of the body, and involves washing the hands, mouth, nostrils, arms, head and feet with water and is an important part of ritual purity in Islam. Wuḍ�?«�?¾ is typically done in preparation for formal prayers (Salat) and also before handling and reading the Qur'an. The activities that invalidate Wuḍ�?«�?¾ include urination, defecation, flatulence, deep sleep, light bleeding and sexual intercourse. Ghusl is a major canonical ablution or a complete washing of the body. It becomes obligatory after sexual intercourse, any discharge of semen, and the completion of menses and post-childbirth bleeding. Taking Ghusl every Friday before the congregational prayer is highly advisable.

When I stated performing ablution (Wuḍ�?«�?¾), I had heat in my mouth and bad odour, and my tongue got straighten and became hard. When I performed ablution, I am uncertain how many times I have washed the required parts or none at all. So I usually re-do the ablution several times. I sometimes say aloud the number of times I have washed a particular part so that I may remember. My mind is in dissonance with the actual physical rituals and many times, I have used so much water that the water tank became empty. I was so exhausted at times, that I cried and cried. I make supplications to God (Allah) to make me stop these compulsions. When I become aware that I was wasting so much water, I became more and more stressful.

Waswâs al-Qahri Fee Ibadah (worship/prayer)

When I perform the daily compulsory prayers, I doubt whether I pronounce the wordings of the Qur’an properly. Because if I do not recite the verses of the Qur’an properly during prayer, my prayer will be rejected. I sometimes stress on the syllables to ensure that I am reading the verses adequately. I also have to make sure that I do the rituals of the prayer in a sequential way and reading the appropriate verses of the Qur ’ an at the appropriate times. When I am in prostration I am not sure that I did the Ruku or not. Ruku is a step of prayer in Islam where someone bows down (places hands on knees) and then goes to Sajdah (placing forehead on the ground). It sometimes takes me 2-3 h to perform 2 Rakats [unit] of prayer which is quite exhausting. I also suffered block head and I had fear of going out and developing fear of death. While I rested, I had many obsessional thoughts and ruminations about not making the prayers in the appropriate ways and the fear of punishment.

Effects of Sihr (Magic/Sorcery)

I had thought or ‘head’ blockage and I could not concentrate and suffered from severe migraine. When I was buying my wedding dress, I was not excited about the marriage and no feeling whatsoever about the incoming wedding. I did not feel myself but I was dissociated from my body. It was as if someone else next to me who is buying the wedding dress. I loss a lot of weight and I felt that something was in my stomach and diaphragm. I had agonising pain and I went to a physician but he stated that I had nothing in my stomach. I started to lose my hair and feel something on my face all the times. I had sweaty hands all the times and this had a repulsive smell.

Psycho-Medical Interventions

S had seen a number of physicians and psychiatrists for her somatic complaints. She was prescribed anti-anxiolytic medications for her psychological conditions and anti-fungal medications for her rashes on her limbs. However, she remained impervious to any form of psychological and medical interventions and she got more depressed. She also sought consultation with a Naturopath without any improvement for her rashes. This case report highlights the need to find other causal factors in the understanding the symptoms presented by S because there are no clear evidence of psychological-medico explanations. There are many signs and symptoms that attributed S’ conditions to various causal agents including supernatural forces such as the envy-related 'evil eye' ('Ayn), Jinn possession, and sorcery (Sihr). This was a turning point of seeking spiritual interventions and Islam focused centred therapy.

Spiritual and Therapeutic Interventions

The most effective method for the diagnosis of Jinn possession is Ruqyah (incantation). Ruqyah can be divided into two categories: Ruqyah which is compliant with the Islamic jurisprudence (Ruqyah Ash Shar’iah) and the deviant Ruqyah which contains polytheistic practices (Ruqyah Ash Shirkiyyah). Rassool indicated that “Individuals with Jinn possession or witchcraft may not tolerate the recitation of the Qur’an during Ruqyah. The effects differ from individual to individual and may include spontaneous changes in involuntary actions (for example, vomiting, involuntary muscular movements) or emotions (for example, screaming, crying, sinister laughing) or showing total resistance to the therapy [2]. There are a number of spiritual interventions that can be used in the treatment of evil eye, Jinn possession and magic. These include, Dhikr, prayer, supplications, Ruqyah and Self-Ruqyah, and Prophetic medicine (Honey, Olive oil and Black Cumin etc.). There is also the use of Cupping (Hijama) and the use of Senna as part of the complementary therapy derived from the Prophetic Islamic medicine.

Dhikr, also spelled Zikr (Arabic: ‘reminding oneself,’ or ‘mention’) is the remembrance of God in which short supplications are repeatedly recited silently. The purpose is the remembrance and the glorification of Allah. Ruqyah is referred as ‘incantation,’ consisting of reciting or writing in the form of Dhikr for the purpose of protection or treatment. It has been suggested that both the remembrance of Allah (Dhikr) and the reciting the Qur’an would protect people with regard to dealing with the evil eye and Hasad (destructive envy), and other kinds of harm from the devils of mankind and the Jinn [2]. All the three substances (Honey, Olive oil and Black Cumin) are used as a complementary medicine with Ruqyah. The recitation of Qur’anic verses (Ruqyah) and ingestion of olive oil are typical treatments for possession by Jinn spirits [20].

S was treated with Prophetic medicine, Ruqya, Dhikr, supplications and prayers, and a modified form of Islamic focused centred therapy. In relation to Prophetic medicine, S. started to use honey on the rashes and make supplications by reading Surah F�?ti�?¥ah (The Opening Chapter of the Qur’an) seven times. After a short treatment of one week the whole rashes disappeared from her limbs. The spiritual interventions with Waswâs al-Qahri are based on the teaching of the Qur’an and Sunnah in the form of self-treatment or treatment by a therapist or an Imam. The spiritual interventions range from seeking refuge in Allah, supplications, Dhikr and Ruqyah.

S’s Waswâs al-Qahri was treated with a mixture of, Dhikr, Ruqya, supplications and prayers, and a modified form of Islamic focused centred therapy. First, there was a need to explain about the identified problems of the contamination experienced by the client and undertaking over purification. It was explained to S that if someone is going to the mosque to pray and it started raining and mud water is splashing on his clothes. In this context, can he perform the prayer? Therapy using the hadiths (sayings) of Prophet Muhammad (SAW) was used to illustrate the statement. It was narrated that Prophet Muhammad (SAW) A woman from the Banu ‘Abdil Ashhal tribe asked the Prophet (SAW): ‘There is a dirty road between me and the Mosque (so my clothes/shoes/feet become soiled)’The Prophet enquired: ‘Is there a cleaner road after it? ‘She replied yes The Prophet said: ‘This (road will wipe out the effect) of that’ [21]. Ummu Salamah was asked by a woman about the state of her clothing which was long, and she would walk on dirty and clean road. Ummu Salamah said she asked Prophet (SAW) about this and he said: ‘The (clean) area after (the dirty one) will cleanse it [22].

Self-treatment using Ruqya was implemented. However, the client was unable to read the Qur ’ an initially. She was encouraged to undertake the Silent Night Prayer (In the middle of the night), supplications during prostrations, making dhikr and giving charity (Sadaqa). She also made use of the Islamqa website to enable her to understand her conditions.

The problems associated with Waswâs al-Qahri Fee Ibadah (worship/prayer) was managed with the use of the ‘Headphone- Recording Technique’. This is a technique which aims to address the sensory problems such as forgetfulness, hearing distortions or sensory processing anomalies which form part of Waswâs al-Qahri Fee Ibadah. The client had doubts whether she had pronounced the wordings of the Qur’anic verses properly during the daily compulsory prayers. There are also the obsessional thoughts and ruminations about not making the prayers in the appropriate ways and the fear of God’s punishment. Whilst performing her prayer, she was given, using a headphone, to listen to a recording of the Qur’anic verses used during the prayer and the directions of the prayer. All S had to do was to follow the recordings of the full prayer and appropriate Qur’anic verses and ignore the Waswâs (whisperings). She also was requested to perform the movements as directed by the recordings during the unit of prayer. After having used this approach on a consistent basis for a number of weeks, S started to undertake the prayer without the recordings using the headphone. However, initially she had difficulties as she still had doubts about the recitation of the Qur'an and the sequential movements ’ requirements during the prayer. She was nudged to continue to finish the prayer even though she had doubts about the quality of the prayer. Subsequently she was able to perform the prayer without any intrusive or obsessional thoughts and compulsions. The ‘Headphone-Recording Technique ’ approach showed to be very effective. She continues to have Islamic psychotherapy [23-25].

Conclusion

Waswâs al-Qahri is a complex disorder which is clearly misunderstood by Orientalist and Eurocentric health professionals. Many Muslims suffer from OCD and scrupulous OCD. Within traditional Muslim communities, psychoform and somatoform dissociation are commonly attributed with Jinn possession and sorcery. This type of possession represents total possession, in which a person's behaviour is totally controlled by a spirit. of the possible overlap between culture-bound syndromes and psychiatric disorders as described in the DSM-V and the International Classification of Diseases. However, when diagnosing OCD, it would be pre-requisite to understand the patient from a cultural and religious context. In Islam, an emphasis on cleanliness, purity and religio-ritualistic behaviours are the norm. In most cases, excessive prayers, supplications and other compulsive behaviours should not be regarded as part of the pathology of OCD. However, when the behaviours are excessive and beyond the demands of religious practices, then they can be considered as OCD symptomatology. However, this must be validated by both health professionals and spiritual leaders (Imam). Spirit possession deserves more interest as a possible idiom of culture-specific expression of dissociation and somatoform behaviours. More research is needed with Muslim communities to better understand this condition as previous research concerning religiosity and OCD has mainly focused on the Judeo-Christian tradition. This has implications for both clinical and spiritual intervention strategies.

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