Medical and Cultural Approach to Obsessive-Compulsive Disorder

Religious obsessive-compulsive disorder (OCD) is a clinically significant subtype characterized by intrusive religious thoughts, like moral transgressions and religious violations, and associated compulsive behaviors.¹ While early studies suggested poorer treatment response compared to other OCD subtypes, recent evidence shows comparable outcomes with appropriate pharmacologic intervention and psychotherapy.² We present a case demonstrating successful management of severe religious OCD through medication optimization and psychotherapy over an 18-month treatment period.

Case Report

Ms A, a 52-year-old woman, presented in January 2023 with severe religious obsessions, which included intrusive thoughts about “the devil getting in her head.” These unwanted thoughts created marked distress and anxiety, with her Hamilton Anxiety Rating Scale score being 29, indicating moderate-to-severe anxiety. She exhibited compulsive movements to remove obsessive thoughts, demonstrating the classic obsession-compulsion cycle. Mental status examination revealed anxious mood with blunted affect, obsessive preoccupation, and no psychotic features. Physical manifestations included severe insomnia (1 to 2 hours nightly) and poor appetite. Due to the severity of her presentation, family accompaniment was required to appointments.

Treatment was initiated with sertraline 25 mg daily and brexpiprazole 0.25 mg daily. Sertraline was increased to 75 mg over a 3-month period, while brexpiprazole was increased to 1 mg. Quetiapine 150 mg was temporarily added for nighttime symptoms and subsequently decreased over 4 months. In addition, psychotherapy was integrated during medication management visits. During initial sessions, the psychotherapeutic approach focused on teaching mindfulness techniques, OCD psychoeducation, and cognitive-behavioral therapy. Family meetings were conducted with her husband and son to discuss mindfulness and how fighting thoughts increases their return. Additional coping strategies included behavioral techniques for managing obsessions between sessions, stress-reduction exercises, and lifestyle modifications emphasizing sleep hygiene and mindfulness meditation practices.

Ms A demonstrated remarkable improvement. By March 2023, religious obsessions no longer caused significant anxiety, and her compulsions had stopped. Her cognitive style changed from reactively fighting thoughts to acceptance and dismissal. By September 2023, her Hamilton Anxiety Rating Scale score reached zero, and intrusive thoughts were reported as “almost not there.” Following successful medication taper, she remained stable on sertraline 25 mg daily. At her 18-month follow-up, Ms A reported controlled symptoms with stable mood, good sleep and appetite, and appropriate judgment and insight.

Discussion

Current literature supports the outcomes of our case. Studies indicate that religious OCD shows treatment responses comparable to contamination-based OCD when managed with pharmacotherapy, particularly selective serotonin reuptake inhibitors.² The addition of antipsychotic medications proves beneficial for treatment-resistant cases.³ Research indicates that thought-action fusion, the maladaptive belief that thoughts are morally equivalent to actions, represents a key cognitive mechanism in religious OCD that responds to acceptance-based approaches.^3,4 Moreover, Ms A’s clinical presentation exemplifies waswas al-qahri (overwhelming whisperings that create doubt and compulsion), the Islamic conceptualization of religious OCD.^5,6 From Islamic perspectives, waswas manifests as repeated, loathsome thoughts that the individual recognizes as wrong but feels compelled to neutralize through rituals.⁶ Ms A’s compulsions to “remove” obsessive thoughts and her fear of divine punishment align specifically with waswas symptomology, as it affected her worship and daily functioning.⁵ Understanding religious OCD through the concept of waswas al-qahri enables culturally sensitive treatment approaches that respect the patient’s religious background.^6,7 This case exemplifies successful pharmacologic management combined with culturally sensitive psychoeducation, resulting in continued remission and improved quality of life for patients with religious OCD.

Article Information

Published Online: June 23, 2026. https://doi.org/10.4088/PCC.25cr04170
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(3):25cr04170
Submitted: December 18, 2025; accepted February 26, 2026.
To Cite: Patel T, Shebak SS. Medical and cultural approach to obsessive-compulsive disorder. Prim Care Companion CNS Disord 2026;28(3):25cr04170.
Author Affiliations: Michigan State University College of Osteopathic Medicine, East Lansing, Michigan (Patel); Department of Psychiatry, Michigan State University College of Human Medicine, East Lansing, Michigan (Shebak).
Corresponding Author: Tirth Patel, MS, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Consent was received from the patient to publish the case report, and information, including dates, has been de-identified to protect anonymity.