Treating Obsessive-Compulsive Disorder with Buddhist Psychotherapy

Dr. Ruwan M Jayatunge M.D.

Obsessive-compulsive disorder (OCD) is an anxiety disorder. The DSM-IV Text Revision defines OCD as the presence of recurrent obsessions and/or compulsions that interfere substantially with daily functioning (DSM IV TR; American Psychiatric Association 2000).

Described in the psychiatric literature since the nineteenth century, obsessive-compulsive disorder could be clearly identified by written accounts centuries earlier. OCD is characterized by intrusive thoughts (i.e. obsessions) and future-oriented worrisome cognitions that are associated with behavioral ritualistic compensations (i.e. compulsions) and anxious arousal. 

Centuries ago, obsessive compulsive disorder was considered the result of possession by outside forces and was treated by witch doctors or religious leaders who tried to rid the patient of his tormenting invader.

Recognizable descriptions of OCD symptomatology are found in the fifteenth-century religious documents on demonology and seventeenth-century observations on abnormally intense religious scruples. Equivalent descriptions of obsessions were reported in the eighteenth and nineteenth centuries by authors, such as Hartley (“fixed and recurrent ideas” in 1774); Esquirol (“reasoning monomanias or partial deliria” in 1838); Krafft-Ebing (“obsessive representation” in 1867); Griesinger (“ruminative sickness” in 1868), and Legrand du Saule (“touching madness” in 1875).

In 1838 the French psychiatrist Jean Dominique Esquirol described the clinical symptomatology of a medical disorder that was quite similar to contemporary OCD. Freud interpreted obsessive-compulsive disorder as unconscious conflicts, which were defensive and punitive.  He further believed that fixation at the anal stage causing OCD.  In modern psychoanalysis, obsessive-compulsive disorder is described as a portrayal of ambivalence, with confusion of thoughts and actions that are paradoxically manifested by rigidity and abnormal behaviors.

Dynamic psychiatry interprets obsessive-compulsive symptoms as a reflection of feelings and thoughts that provoke aggressive or sexual actions that might produce shame, weakness, or loss of pride.

Today, obsessive-compulsive disorder is viewed as a neuropsychiatric disorder, mediated by pathology in specific neuronal circuits. According to some researchers serotonin transporter polymorphism has been implicated in obsessive-compulsive disorder. In addition structural alteration (volumetric differences in the cortical and thalamic regions) of the thalamocortical pathways may contribute to the functional disruptions of frontosubcortical circuits observed in OCD. OCD symptoms seem to be associated with hyperactive error-related brain activity.  However OCD is still probably the least understood of all the major psychiatric syndromes.

Moral Scrupulosity (pathological guilt about moral or religious issues) often associated with obsessive-compulsive disorder (OCD). Individuals with OCD appear far more sensitive when it comes to moral dilemmas. Obsessive–compulsive symptoms are often associated with cognitive biases and can cause significant distress and impairment in daily functioning. The aforementioned studies indicate that understanding the moral psychology of OCD may illuminate its etiology.

There is much ambiguity and heterogeneous nature in OCD and attachment insecurities are connected with OCD. OCD is a chronic and heterogeneous condition characterized by sudden, recurrent upsetting cognitions that intrude into consciousness (obsessions), and rule governed acts that the person feels driven to perform (compulsions).  Both obsessions and compulsions are usually recognized by the individual as excessive or unreasonable.

There are different types of Obsessive-Compulsive Disorder. They are mainly Checking Contamination, Hoarding and Intrusive Thoughts. Harm OCD is another manifestation of Obsessive Compulsive Disorder in which an individual experiences intrusive, unwanted, distressing thoughts of causing harm. These harming thoughts are perceived as being ego-dystonic (thoughts are inconsistent with the individual’s values, beliefs and sense of self).  Individuals with aggressive/sexual/religious obsessions frequently experience uncertainty about whether they might act on their intrusive thoughts. This pathological doubt often results in high levels of guilt, self-criticism, or even self-loathing.

The emotion of guilt plays a pivotal role in the genesis and maintenance of Obsessive-Compulsive Disorder. The feeling of guilt is a complex mental state underlying several human behaviors in both private and social life. From a psychological and evolutionary viewpoint, guilt is an emotional and cognitive function, characterized by pro-social sentiments, entailing specific moral believes, which can be predominantly driven by inner values (deontological guilt- deriving from the transgression of a moral rule) or by more interpersonal situations (altruistic guilt- relying on the assumption of having compromised a personal altruistic goal). People with OCD are more sensitive to deontological guilt.

Early psychodynamic theories posited a link between obsessive-compulsive disorder (OCD) and heightened moral sensitivity that has become again relevant in contemporary cognitive behavioral models. Behavioral models of OCD   posit that compulsive behaviors are a form of avoidance that maintain obsessive fears via negative reinforcement (anxiety reduction) and by blocking opportunities for habituation to feared objects and situations. Cognitive models implicate maladaptive beliefs such as inflated sense of responsibility, perfectionism, importance/control of thoughts in the maintenance of the disorder. Moreover dysfunctional cognitions are important in the etiology and maintenance of OCD.

Biological models of obsessive-compulsive disorder propose anomalies in the serotonin pathway and dysfunctional circuits in the orbito-striatal area and dorsolateral prefrontal cortex. The cognitive-behavioral model of obsessive-compulsive disorder, which has some empirical support but does not fully explain the disorder emphasises the importance of dysfunctional beliefs in individuals affected.

OCD are associated with   neuroticism, fear, depression, and sleep disorders. Having a lifetime diagnosis of OCD is associated with an increased likelihood of developing depression, alcohol abuse, drug abuse, phobic disorders, and antisocial personality disorder. Most individuals with obsessive–compulsive disorder (OCD) have comorbid personality disorders (PDs), particularly from the anxious cluster.

OCD can impair free will. Free will is the ability to act at one's own discretion. According to the traditional Western concept of freedom, the ability to exercise free will depends on the availability of options and the possibility to consciously decide which one to choose.  

Some believe that that free will is an illusion. Spinoza thought that there is no free will and David Hume argued that free will is nothing more than a merely "verbal" issue. Free will has been characterized in terms of retaining control, whereas mental disorders have been characterized in terms of decreased control. Obsessive-compulsive disorder can interfere with a person’s capacity to control the nature of his mental states.  OCD is generally characterized by a decrease of control. 

The spectrum of obsessive-compulsive disorder is extensive. The Buddhist psychology discusses several major forms of obsessions and compulsions and its philosophical and spiritual dimensions. Renowned Clinical Psychologist Padmal de Silva revealed that a very early Buddhist text has an interesting account of a monk named Sammunjani (at the time of Buddha -over 25 centuries ago), who engaged in what can only be described as compulsive behavior. Adding up in one of the Buddhist Jathaka stories (in Kudhala Jātakaya) a farmer with an obsessive fixation to a mammoty had been described.  

The Anusaya Sutta of the Anguttara Nikaya profoundly discuss about obsessions and compulsions in universal form. The word Anusaya is usually translated as latent tendencies or inclinations. According to the Buddha there are seven major obsessions.  These obsessions are the obsession of sensual passion, the obsession of resistance, the obsession of views, the obsession of uncertainty, the obsession of conceit, the obsession of passion for becoming and the obsession of ignorance.

As explained by the Buddha Anusaya or the latent tendencies are defilements as well as the roots of suffering. It creates an existential vacuum. Craving (taṇhā) and ignorance (avijjā) fuel latent tendencies. By these latent tendencies could be eradicated by illuminating   the first three fetters (sanyojanas) of the mind, namely self-view (or identity), clinging to rites and rituals, and skeptical doubt.   

In the therapeutic settings Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) is the first-line treatment for patients with obsessive-compulsive disorder. The development of serotonin specific reuptake inhibitors (SSRIs) led to effective medication. Cognitive behaviour therapy, combined at times with SSRIs, is now considered the most effective treatment. Moreover Buddhist mindfulness practice can be used to treat obsessive compulsive disorder. The word mindfulness originally comes from the Pali word sati, which means having awareness, attention, and remembering. Mindfulness can simply be defined as “moment-by-moment awareness”. Buddhist psychology and philosophy have the potential of contributing to the cognitive behavioral conceptualization and treatment of psychopathology.

Mindfulness Based Cognitive Behavioral Therapy (MBCT) is recommended for the treatment of OCD. MBCT was developed by Zindel Segal and colleagues. It contains elements from Buddhist Vipassana and Zen meditation practice.   

Mindfulness-based cognitive therapy is a novel, theory-driven, psychological intervention designed to treat OCD. MBCT is based on Jon Kabat-Zinn’s stress reduction programme at the University of Massachusetts Medical Center. It includes meditation techniques to help participants become more aware of their experience in the present moment, by tuning into moment-to-moment changes in the mind and the body.  It helps to enhance self-management.  

Some researchers recommend Acceptance and Commitment Therapy for OCD.  Acceptance and Commitment Therapy (ACT) is a psychological intervention that has wide clinical applications with emerging empirical support. It is based on Functional Contextualism and is derived as a clinical application of the Relational Frame Theory, a behavioral account of the development of human thought and cognition. The six core ACT therapeutic processes include: Acceptance, Diffusion, Present Moment, Self-as-Context, Values, and Committed Action. Acceptance and Commitment Therapy contains Buddhist tenets such as   the ubiquity of human suffering, the role of attachment in suffering, mindfulness, wholesome actions, and self. 

Behavior modification too has been successfully used to treat obsessive-compulsive disorder. Behavior modification focuses on using principles of learning and cognition to understand and change individual's erroneous behavior. Specific behavior-change techniques used by modern behavior therapists today are much similar to the behavior-change techniques used in Early Buddhism. The Buddhist Jathaka stories narrate such behavior modification techniques.

In Buddhist Psychology mental health is much more than the absence of mental illness. Buddhist psychotherapy views usual state of mind as significantly underdeveloped, dysfunctional, and outside of conscious control. There are a number of defense mechanisms within a person’s mind that conceal the level of dysfunction from oneself and others. In OCD these dysfunctions are more prominent. In OCD there is a void in philosophical and spiritual dimensions and Buddhist psychotherapy addresses these voids. Also Buddhist psychotherapy does not reject the neurobiological accounts of OCD. Buddhist psychotherapy provides psychological methods of analyzing human experience and inquiring into the potential and hidden capacities of the human mind.

Buddhist psychotherapy deals with OCD related “opposite thinking” with conscious, mindfulness manner.  The main objective of Buddhist psychotherapy in OCD is being mindful of one’s momentary experience without judgment, harmonize emotions and past traumatic memories, creating cohesion of one’s sense of self, being analytical about dysfunctional processes associated with OCD, establish insight-oriented dialog to identify defilements,   cultivate the mind through meditation which helps to evoke insight and activate the healing potential of the brain.

Meditation helps to combat anxiety which is the core component of OCD. With meditation brain plasticity is enhanced and it restores the brain structure that has been altered by OCD. In addition Buddhist psychotherapy addresses spirituality which been described as being ‘where the deeply personal meets the universal’; a sacred realm of human experience. Spirituality is an important aspect of holistic care and usually associated with better mental health. According to some Western Psychologists spirituality is ‘the forgotten dimension’ of mental health care. Spirituality including transcendent experiences promotes healing effects.

Buddhist psychology has focused for over 2,500 years on cultivating exceptional states of mental well-being as well as identifying and treating psychological problems such as OCD. Buddhist psychotherapy is comprehensive and multi-modal in its praxis. It helps to empower the patient. It is a unique psychotherapy guiding the patients through spiritual path towards self-healing.   

References

Abramowitz, J.S., Taylor, S., McKay, D. (2009).Obsessive-compulsive disorder. ;374(9688):491–499.

Abramovitch, A., Doron, G., Sar-El, D., Altenburger, E. (2013). Subtle threats to moral self-perceptions trigger obsessive-compulsive related cognitions. Cognitive Therapy and Research 37(6), 1132-1139.

Aich, T.K.(2013).Buddha philosophy and western psychology. Indian J Psychiatry. ;55(Suppl 2):S165-70.

Baer, L. (1993). Behavior therapy for obsessive compulsive disorder in the office based practice, J. Clin. Psychiat., 54 suppl , 6, 10-5.

Basile, B., Mancini, F., Macaluso, E., Caltagirone, C., Frackowiak, R.S., Bozzali ,M. (2011).Deontological and altruistic guilt: evidence for distinct neurobiological substrates. Hum Brain Mapp. ;32(2):229-39.    

Basile, B., Mancini, F., Macaluso, E., Caltagirone, C., Bozzal,i M. (2014). Abnormal processing of deontological guilt in obsessive-compulsive disorder.Brain Struct Funct. ;219(4):1321-31.

Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.

Bodhi, B. (2000). A comprehensive manual of Adhidhamma. Seattle: BPS Pariyatti.

Culliford L. (2002) Spirituality and Clinical Care. BMJ, 325, 1434-5.

Davis, D.M ., Hayes, J.A. (2011). What are the benefits of mindfulness? A practice review of psychotherapy-related research.Psychotherapy (Chic). ;48(2):198-208.

de Haan, S et al(2013). Being free by losing control: What Obsessive-Compulsive Disorder can tell us about Free Will. Retrieved from http://philpapers.org/rec/RIEBFB

de Silva, P., Rachman, S. (2009). Obsessive–compulsive disorder: The facts. Oxford: Oxford University Press.

Doron, G., Moulding, R., Kyrios, M., Nedeljkovic, M., & Mikulincer (2009). Adult attachment insecurities are related to obsessive compulsive phenomena. Journal of Social and Clinical Psychology, 28, 1025-1052.

Eisenberg, N.(2000). Emotion, regulation, and moral development.Annu Rev Psychol. ;51:665-97.

Franklin, S. A., McNally, R. J., & Riemann, B. C. (2009). Moral reasoning in obsessive-compulsive disorder. Journal of Anxiety Disorders, 23, 575-577.

Fung, K.(2014).Acceptance and Commitment Therapy: Western adoption of Buddhist tenets? Transcult Psychiatry. 1. pii: 1363461514537544.

Hanwella, R. & Perera, R., (2011). 'Delusional' obsessive compulsive disorder responding to behaviour therapy: a case report. 2(1), pp.33–35.

Glannon, W.P. (2013). Obsessions, Compulsions, and Free Will.Philosophy, Psychiatry, and Psychology 19 (4):333-337.

Germer, C. K. (2005). Mindfulness: What is it? What does it matter? In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 3–27). New York: Guilford Press.

Harrison, B. J., Pujol, J., Soriano-Mas, C., Hernández-Ribas, R., López-Solà, M., Ortiz, H., et al. (2012). Neural correlates of moral sensitivity in obsessive compulsive disorder. Arch. Gen. Psychiatry 69, 741–749.

Hertenstein, E., Rose, N., Voderholzer, U., Heidenreich, T., Nissen, C., Thiel, N., Herbst, N., Külz ,A.K. (2012).Mindfulness-based cognitive therapy in obsessive-compulsive disorder - a qualitative study on patients' experiences. BMC Psychiatry.  31;12:185.

Hezel, D. M., Riemann, B. C., McNally, R. J. (2012). Emotional distress and pain tolerance in obsessive-compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, 43, 981-987.

Hollander E, Cohen LJ. Impulsivity and compulsivity. Washington, D.C: American Psychiatric Press; 1996.

Jayatunge.R.M.(2015). Psychological Aspects of Buddhist Jathaka Stories. Godage Publishers. Sri Lanka.

Jenike, M.A.(1983). Obsessive compulsive disorder.Comprehensive Psychiatry Volume 24, Issue 2.Pages 99–115.

Jenike, M.A.(2004).Clinical practice. Obsessive-compulsive disorder.N Engl J Med. 5;350(3):259-65.

Kagan, J. (2005). Human morality and temperament.Nebr Symp Motiv. ;51:1-32.

Kelly, B.D.(2008).Buddhist psychology, psychotherapy and the brain: a critical introduction. Transcult Psychiatry.  ;45(1):5-30.

Kolada, J. L., Bland, R. C., & Newman, S. C. (1994 January) Obsessive-Compulsive Disorder. 89 (s376), 24-35.

Kozak, M. J., & Foa, E. B. (1997). Mastery of obsessive-compulsive disorder: A cognitivebehavioral approach. San Antonio, TX: The Psychological Corporation.

Mancini, F., Gangem,i A.(2015).Deontological guilt and obsessive compulsive disorder.J Behav Ther Exp Psychiatry.  16. pii: S0005-7916(15)00070-1.

Miguel, E.C., Rauch, S.L., Jenike, M.A. Obsessive–compulsive disorder. Psychiatr Clin North Am. 1997;20:863–883.

Neale, M.(2012). What Buddhist Psychotherapy Really Is. Retrieved from http://www.milesneale.com/wp-content/uploads/2012/02/WhatBuddhistPsychotherapyReallyIs.pdf

Ravi Kishore, V.v, Samar, R, Janardhan Reddy, Y.C, Chandrasekhar ,C.R., Thennarasu K.(2004). Clinical characteristics and treatment response in poor and good insight obsessive-compulsive disorder.Eur Psychiatry.  ;19(4):202-8. 

Riesel, A., Richter, A., Kaufmann, C., Kathmann, N., Endrass, T.(2015).Performance monitoring in obsessive-compulsive undergraduates: Effects of task difficulty.Brain Cogn.  4;98:35-42.

Rogers M, Wattis J.(2015).Spirituality in nursing practice. Nurs Stand.  27;29(39):51-7.

Rotge, J.Y.1., Guehl, D., Dilharreguy, B., Tignol, J., Bioulac, B., Allard, M., Burbau,d P., Aouizerate, B. (2009).Meta-analysis of brain volume changes in obsessive-compulsive disorder.Biol Psychiatry.   1;65(1):75-83. 

Stein, D.J.(2012). Philosophy and Obsessive–Compulsive Disorder. Philosophy, Psychiatry, & Psychology Volume 19, Number 4, pp. 339-342.

Steketee, G., & Lam, J. (1993). Obsessive compulsive disorder. In T. R. Giles (Ed.), Handbook of effective psychotherapy (pp. 253–278). New York: Plenum.

Swinton, J. (2001) Spirituality and Mental Health Care: Rediscovering a Forgotten Dimension. London: Jessica Kingsley.

Tangney, J.P., Stuewig, .J, Mashek, D.J.(2007).Moral emotions and moral behavior. Annu Rev Psychol.  ;58:345-72.

Toneatto, T.(2002). A metacognitive therapy for anxiety disorders: Buddhist psychology applied. Cognitive and Behavioral Practice Volume 9, Issue 1, , Pages 72–78.

Stein, D.J.(  ‎2002 ).  Obsessive-compulsive disorder.Lancet.3;360(9330):397-405.

Wallace, B.A., Shapiro, S.L.(2006).Mental balance and well-being: building bridges between Buddhism and Western psychology.Am Psychol.  61(7):690-701.

Williams, J.M., Kuyken, W.(2012). Mindfulness-based cognitive therapy: a promising new approach to preventing depressive relapse.Br J Psychiatry. ;200(5):359-60.

Zambrano-Vazquez, L., Allen, J.J. (2014).Differential contributions of worry, anxiety, and obsessive compulsive symptoms to ERN amplitudes in response monitoring