Cognitive behavioral therapy is very helpful, and now magnetic stimulation shows promise Judy Siegel-Itzkovich reports Cleanliness is next to godliness, but when it occupies much of a person’s time and is pursued to the extreme, it becomes an obsession in one’s thoughts and a compulsion that drives one to abnormal behavior.Excessive attention to cleanliness and warring against germs are the most common aspects of obsessive-compulsive disorder, which affects around 1% to 3% of the world’s population, whatever their culture, intelligence, gender, age, ethnic origin or socioeconomic status. It can hit the famous, the infamous and the ordinary. This anxiety disorder is a disrupting and debilitating condition that affects not only the victim but also their family and friends.As with some other mental disorders such as schizophrenia, symptoms usually appear around the age of 20, but they can manifest at any age, even among toddlers. Studies done on twins have shown that OCD is three or four times more common in one identical twin if the other has it, but even then, it raises the risk no more than a few percentage points, and there is no direct inheritance.According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, obsessions are repetitive, intrusive and distressing thoughts, ideas, images or urges that often are experienced as meaningless, inappropriate and irrelevant and persist despite efforts to suppress, resist or ignore them.Compulsions are repetitive, stereotyped behaviors and/or mental acts that are used to diminish the anxiety and distress associated with the obsessions.PRO F. JONATHAN Huppert, a clinical psychologist at the Hebrew University of Jerusalem’s Laboratory for the Study and Treatment of Anxiety has conducted much research on OCD and treated many patients.Born in New Jersey, he did his bachelor’s degree at the University of Pennsylvania and doctoral degree at Boston University. Huppert was on the University of Pennsylvania’s faculty and researched OCD there before he and his wife Dr. Donna Zfat, a cardiologist at Hadassah University Medical Center, came on aliya a decade ago. “The epidemiology for OCD is somewhat controversial. The standard psychiatric questionnaire is not very reliable. So it’s hard to know whether there is more OCD than there used to be,” he said in an interview with The Jerusalem Post.He explained that cleanliness involves about 30% of OCD problems. “Our bodies are full of bacteria, some of which are harmful and some beneficial, but many people see them as bad,” Huppert said, as he recalled a man who drenched his skin with bleach all the time.“It is not uncommon for people suffering from OCD organize their homes in a way to avoid things from being contaminated and to develop elaborate rituals. It’s easier for family members to go along than to fight the problem,” he continued.Asked whether the devout of different religions have a different prevalence of OCD, Huppert – who is modern Orthodox – said Christians with OCD may be more fixated on intrusive thoughts, while observant Jewish and Muslims may exaggerate scrupulousness about religious ritual.“From my clinical experience, I don’t think the modern Orthodox are at as great a risk of scrupulous compulsions as the ultra-Orthodox [Haredim].“Haredim are less likely to feel ‘contaminated’ by AIDS, but they worry about niddah [physical contact between a husband and wife from the beginning of her menstrual period and until a week after it ends], about praying properly or about cleaning hametz [leaven] before Pesach [Passover], about having clean hands and bodies after going to the bathroom before praying, and the like.”Huppert has had patients who spend long periods applying their phylacteries properly for prayers. One woman patient refused to eat anything made of flour the whole year round because of the fear that they had existed during Passover rather than being thrown out.He treated her with cognitive behavioral therapy in which she was exposed to closed bags of flour that were gradually opened. Another patient who was afraid of mixing dairy and meat utensils and plates used only disposables. He added that a yeshiva student who continues praying when all his peers are already in the dining room clearly has a problem.“As cleanliness, especially before reciting prayers, is required by the Torah, having a clean body after relieving oneself is demanded.But OCD patients may spend an hour in the bathroom making sure they are clean before thrice-daily prayers. This adds up to a lot of wasted time,” he said.OCD among the observant is apparently not more prevalent among observant Jews, but when they do suffer from it, said the clinical psychologist, the obsessions and compulsions are more likely to involve religious matters.“We did interviews with 15 Haredi rabbis on whether they knew about OCD and how they would deal with it. We were pleasantly surprised. All but one,” recalled Huppert, “knew about it and gave psycho-biological reasons for it. Only one thought it was a ‘spiritual problem.”Huppert is accepted in the Haredi community as a therapist because of his reputation going back to the US and their preference of a religious psychologist. “They worry that a secular psychologist would use Sigmund Freud to blame their religious practices for the problem.”Originally developed to treat depression, cognitive behavioral therapy is today considered the best treatment for OCD. A common type of structured talk therapy, it makes it possible for patients to develop personal coping strategies to change unhelpful patterns of thoughts, behaviors and emotions.Combining the basic principles from cognitive and behavioral and psychology, it is a relatively short-term therapy, unlike psychoanalysis, which looks for the unconscious meaning behind behaviors and one’s childhood and relationship with one’s parents.CBT focuses on treating specific problems, said Huppert, with the therapist helping the patient to find and practice ways to reduce symptoms and reach a goal. A person who fears being infected with HIV by touching an object, for example, could be taken to a medical library to touch and read books about the AIDS virus that were previously read by HIV carriers or go to the bathroom in a hospital where carriers are treated. Gradual exposure reduces the fears of contamination.“Until the mid-1960s, before CBT, people saw no solution. Therapists claimed the disorder was resistant to treatment, but CBT is effective in 50% to 60% of cases. Not everybody goes into complete remission, but most find their symptoms are much relieved and they can have a fulfilling life.”It may be possible to treat OCD patients via telemedicine, over a computer, and not only in face-to-face encounters, Huppert suggested.DR. AV IGDOR (Victor) Bonchek, a longtime Jerusalem psychologist and ordained Orthodox rabbi, wrote a book in 2009 called Religious Compulsions and Fears: A Guide to Treatment. Born in Cleveland, a student at Bnei Brak’s Ponevezh Yeshiva, ordained by the Ner Israel Rabbinical College in Baltimore and a graduate in clinical psychology from New York University, Bonchek came on aliya with his family in 1971. He taught at the Hebrew University of Jerusalem’s School of Education and School of Social Work for many years and has long had a private practice, during which he has treated a large number of OCD patients, many of them religious.He gives partial credit for his ideas and techniques to two mentors: Dr. Joseph Wolpe of Temple University who pioneered behavior therapy back in the 1950s and whose CBT course he attended in 1969, and Dr. Giorio Nardone of Italy, a strategic therapist with whom Bonchek studied for several summers.Bonchek compares observing the commandments of the Torah to “holding a young dove in one’s hands. If he grasps it too tightly, he kills it. If he does not hold it firmly enough, it will fly away, and he will lose it. There needs to be a delicate balance to fulfill the Torah’s commandments in a healthy way.”Religious women who observe family purity laws and suffer from OCD can get completely bogged down once a month when examining themselves for blood to determine when they are permitted to go to the ritual bath. Such compulsions can make it impossible for them to get pregnant. There are people who are compulsive about kissing mezuzot on doorposts, even though these are major spreaders of germs in public institutions, including hospitals.Bonchek also knows of a Haredi man who had an uncontrollable urge to give charity; he never turned down a beggar or even a mailed request for a contribution and earned less than he handed out.Kashrut is another halachic demand that lends itself to obsessions. OCD patients may constantly look for insects in the vegetables, beans or rice, or endlessly wash their hands after touching a ‘meat’ spoon before touching a dairy one. Despite such repeated tasks, worry about having a non-kosher kitchen can become a constant fear.Bonchek said he was told that the Ukrainian-born sage Rabbi Yaakov Yisrael Kanievsky, who was known to followers as The Steipler and died in 1985, showed a great understanding of obsessive-compulsive behavior among the ultra-Orthodox when he was in contact with an American psychologist, even though the rabbi never studied psychology. He sent OCD sufferers for treatment.When a compulsive ritual is performed, the person feels “immediate relief” afterward from his “inner tension.” If something positive occurs after the behavior, it is reinforced.If a negative event occurs after the behavior, it is regarded as punishment. If there is no significant event after the behavior, there is “extinction,” and the act will eventually “fade out.”Despite his Orthodox background and appearance, Bonchek has plenty of secular patients who seek help. When a patient is helped to properly confront his behavior, extinction can get a boost. Sometimes, Bonchek said, a “buddy” who is regularly in the patient’s environment can help when the therapist is not around. An important principle in CBT treatment, he wrote, is that it has to proceed gradually, step by step, and in a precise order. In addition, guided imagery is used.“CBT is easier to use for patients suffering from the compulsion to do things than those with mental obsessions. Some people have one or the other, but most have both obsessions and compulsions,” Bonchek said.OCD victims are rarely suicidal. “I remember reading in The New York Times years ago of a patient who shot himself in the mouth and didn’t die but cured himself of his OCD.“As the frontal lobe of the brain is involved in the disorder, he knocked out the part that was causing trouble. But of course, this ‘method’ is not recommended,” he added with a smile. Anxiety itself can, in normal behavior, protect you from danger, but when exaggerated, it can be devastating.Another common symptom OCD symptom involves safety. “Some patients always have to check things and feel in control.They go again and again to check whether a door is locked, a window closed and the gas turned off before they go to sleep.”While CBT has so far proven itself to be most effective in treating the disorder, Bonchek predicts that deep transcranial magnetic stimulation will be an effective, safe and non-invasive treatment for OCD.A Jerusalem company named Brainsway has developed a medical device that uses “H-coil” technology for TMS. Founded 14 years ago in the capital’s Har Hotzvim neighborhood, with its US headquarters in New Jersey, the company maintains that by sending an electric current through a coil, an intense magnetic field is generated to treat the brain.Still, in the research phase of clinical trials, the device has been patented; it is in various stages of regulatory approval for different indications, from OCD to depression. A multicenter study in OCD was recently conducted on the device at 11 medical centers, one in Israel, one in Canada and nine in the US.Almost 100 patients who previously failed to respond well to drug or CBT underwent 30-minute sessions with the Brainsway system five times a week over six weeks. They showed statistically significant improvement in their condition compared to a placebo group.