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ISLAMIC MEDICAL EDUCATION RESOURCES-03

0101-MENTAL and NERVOUS CONDITIONS

Lecture to 3rd year medical students on 20th January 2001 by Professor Omar Hasan Kasule Sr.

A. DISTURBANCE OF CONSCIOUSNESS and MENTAL STATE

DEFINITIONS

Disturbed states of consciousness are coma and semi-coma. The causes of coma are trauma, infection, poisoning, psychiatric conditions, shock, alcohol, epilepsy, increased intra-cranial pressure, opiates, and uremic/metabolic conditions. Brain death and the persistent vegetative state are forms of loss of consciousness.

 

SALAT

Impairment of consciousness has an impact on salat. In its simplest form it may be forgetfulness in salat, al sahawu fi al salat (KS 321) which is remedied by a corrective measure like the prostration of forgetting, sujuud al sahaw. If a salat is forgotten it is offered when remembered, idha nasiya al salat yuswaliha ‘insa ma yadhkurha (KS 315). Doubts may arise in the course of salat regarding the number of raka’ats or other actions performed, al shakk fi al salat (KS 321), reflecting underlying problems of wakefulness and full mental attention. The mental state may also not be fully awake in some cases of salat in terminal illness, al salat fi maradh al mawt (KS 349). The Law has described salat actions for the shocked or unconscious person, salat al mughma ‘alayhi (KS 506). In a situation of complete loss of consciousness, there is no obligation to pray. In semi-coma, syncope, or stroke the patient tries to pray as much as they can. Care must be taken in the case of stroke to make sure that the patient will not fall down and injure himself due to the limb paralysis or paresis. If a person dozes he should stop salat, sleep and resume only when conscious of what he is reading (KS 315). It is forbidden to perform salat while asleep, al salat naiman (KS 311: Nisai K20 B21; Ahmad 4:435, 442, 443; Ahmad 6:56, 202, 205, 259, 268; Tayalisi H2645). In situations of fright with inability to concentrate, qasr al salat fi haalat al khawf

 

SAUM

There is no penalty for forgetting in saum, al nisyaan fi al saum (KS 333: Musnad Zaid H237 & 241). The person who eats accidentally in Ramadhan just resumes fasting until the day is completed. Patients with syncope and those with recent stroke should be excused from fasting to enable necessary medical procedures. The obligation of fasting is dropped if the patient is in coma or is fully unconscious.

 

HAJJ

Any impairment of consciousness results in delay of hajj because of the physical difficulty involved and the crowding. Syncope due to postural hypotension and heat stroke are common in hajj and are causes of temporary impairment of consciousness. Hajj rites should be suspended until full consciousness is regained.

 

‘AADAAT

Discussion of consciousness arises often in medical practice. Semi-conscious patients or those in coma are fed without their consent under the purpose of preserving life, hifdh al nafs. They are legally not competent to make decisions about their nutrition.

 

MUNAKAHAT

Sexual relations with a semi-conscious spouse raise the issue or consent in sexual relations. The Law makes it obligatory for each of the spouses to accede to the sexual needs of the other in order to protect them against sexual transgression, ihswaan. The obligation is more emphatic on the wife. There is however no clear directive on whether a non-consenting wife can be forced to have sex with her husband. The Law provides ways of resolving marital disputes involving sexual rights but does not explicitly say that a woman can be forced. This implies that some form of consent is needed. The semi-conscious patient cannot give such consent making it problematic to have sexual relations with her.

 

Psychosocial stress can lead to a state of altered consciousness and mentation that impair judgment. Pronouncements of divorce or khulu’u under such conditions have no legal effect because the person concerned is deemed to have lost legal competence. In a similar way conclusion of marriage contracts is not possible because of legal incompetence.

 

MUAMALAT

Transactions under duress, an nahyu ‘an bay’I al mudhtarr (KS 128), may have no legal standing because of legal incompetence. Contracts by a semi-conscious person have no legal effect because such a person is incompetent. However a guardian, wali, on behalf of the unconscious, can conclude valid contracts.

 

AL QADHA

Court testimony by a semi-conscious person is not allowed. There is reduced legal or civil liability for crimes and contracts under the influence of ordinary psychiatric medication. Liability is not reduced for crimes and contracts committed under the influence of alcohol or illegal drugs.

 

B. PSYCHIATRIC CONDITIONS

PERSONALITY DISORDERS

Description: The common personality disorders are: paranoid, schizoid, compulsive, hysterical, narcissist, avoidant, and dependent, passive-aggressive, anti-social, borderline disorders. The underlying causes may be biological organic brain syndromes, genetic, developmental, social (psychodynamic, learned behavior, environment), and biochemical. The stress on the patient and the family during medical and surgical procedures usually precipitates such crises in persons with underlying labile personality disorders.

 

Ibadat: Personality disorders not accompanied by cognitive effects have no impact on ibadat. Severe personality disorders may be reason for not performing hajj because the stress could precipitate a crisis. Saum and hunger could be a stressful condition precipitating a crisis however each case should be judged on its own merits.

 

‘Aadaat: Personality disorders may lead to disturbed or abnormal habits in eating, drinking, or excrete disposal that could impair both individual and public health.

Munakahaat: Severe personality disorders as contra-indication for marriage. The purpose of marriage is to create a permanent bond between a husband and wife such that procreation and childrearing are possible. These purposes cannot be fulfilled in cases of severe personality disorders that make married life and company impossible.

 

Muamalaat: There may be some doubts about the legality of contracts concluded by persons with personality disorders that affect free will.

 

Qadha: The court may consider legal incompetence in cases of crime due to underlying and perhaps genetically determined personality disorder on the grounds that the individual has no free will.

 

NEUROTIC and PSYCHOTIC DISORDERS

Definition: Neurotic disorders are anxiety, fear, compulsive-obsessive behavior, and other minor psychiatric disorders. Psychotic disorders are severe conditions such as schizophrenia, paranoia, and mood disorders (depression, suicide, mania, bipolar disease).

 

Ibadat: Obligatory salat should be delayed in cases of anxiety because concentration will not be possible, ishtighaal al fikr fi al salat (KS 310: Bukhari K21 B18). Compulsive-obsessive behavior about passing flatus makes salat difficult. The victim feels like he is passing flatus whenever he starts praying. He may have to be advised to ignore the ‘flatus’ and continue the salat. Compulsive-obsessive behavior may be the cause of forgetfulness in salat. Psychiatric disease of any severity does not affect the obligation of paying zakat because zakat is an obligation related to the wealth and the not the individual. Psychiatric illness of sufficient severity to affect legal competence is sufficient excuse to exempt the victim from the obligation of saum.

 

‘Aadaat: Personality disorders may be associated with self-neglect. The victim neglects personal hygiene and is often dirty and unkempt. He is thus a risk to personal and public health.

 

Munakahaat: Many problems can arise in marriage of a spouse with madness, man tazawwaja imra at wa biha junuun (KS 550). Treatment of the disease may have to be attempted before resorting to divorce. In some cases the marriage may be deemed void or irregular because the mental condition of one of the spouses was such that they did not have sufficient legal competence to conclude a marriage. In a similar way divorce pronouncements by an insane person, talaaq al majnuun, may not have immediate legal effect unless confirmed by a competent court.

 

Muamalaat: Contracts by a schizophrenic or a patient with mood disorders clouding clear thinking are void.

 

Qadha: Evidence by a psychiatric patient is evaluated in view of the type of cognitive or personality defects because some may be acceptable. The evidence of patients with mood disorders must be considered in the light of their clinical conditions.

 

SEXUAL DISORDERS

The common sex related disorders are: paraphilias (exhibitionism, transvetism, voyeurism, pedophilia), incest, bestiality, sadism, masochism, bondage, and necrophilia. Problems of gender identity could lead to trans-sexuality, bisexuality, and homosexuality. Psychosexual dysfunction includes: impotence, ejaculation disorders, vaginismus, frigidity, and lack of libido. Sexual disorders usually have no direct impact in ibadat,  aadaat, or mu’amalaat; they however are intimately related with marriage and divorce. The following are situations for which legal positions need to be worked out: divorce/khuluu on the basis of lack of libido, divorce on the basis of sexual disorder such as sadism or masochism, divorce on the basis of transsexual behavior, divorce on the basis of male impotence or female vaginismus/frigidity, and the validity of a marriage contract in cases of known and established lack of libido. Other issues may arise for those with excessive uncontrollable sexual drives. Fasting may help control sexual desire. Obligatory medical or surgical treatment may be considered in public interest. In cases of qadha some forms of sexual disorders may harm social respectability, muruat, and therefore the competence to be a witness however each case should be considered on its own merits.

 

STRESS DISORDERS

Stress is a physical and emotional state. It can be controlled internally salat, dhikr, and I’tikaf. Stress may lead to wrong unintended decisions in transactions. It may produce adverse effects on marriage leading to divorce. It also affects ‘aadaat like eating; appetite may be increased or decreased. Concentration in salat is affected by stress. Hajj and saum may increase the stress level. Observation of acts of ibadat should be considered for each case on its own merits.

 

C. DEGENERATIVE CONDITIONS

EPILEPSY

An epileptic under control can pray, fast, and undertake hajj. They have to make sure that drugs are taken regularly and that conditions that trigger attacks are avoided.

 

PARKINSONISM

Movements of salat may be difficult in advanced Parkinson’s disease but are possible. In advanced cases hajj may be a physical challenge. Unintentional injury to self and others is likely because of uncontrollable movements; special precautions may have to be taken.

 

DEMENTIA

Demented patients cannot remember verses of the Qur’an properly and may confabulate. They should follow and not lead in salat. Dementia that does not impair cognition does not exempt from saum and hajj. Court testimony of elderly demented patients should be evaluated in the light of their memory and cognition. In many cases dementia is incipient and may not be suspected; special tests of competence should be administered by the qadhi before proceeding. Dementia may be a reason for exclusion from positions of leadership. However the leadership potential of the elderly should not be forgotten altogether. What they may lack in short term memory and cognition can be made up from the accumulated wisdom of experience.

D. NEUROLOGICAL CONDITIONS

NMJ disease such as myasthenia gravis limits salat movements and may make hajj difficult. The patient undertakes physical activities to the best of ability. Neuropathies may be mono-neuropathies or polyneuropathies caused by trauma, toxins, metabolic disorders or associated with various disease conditions. Pain from neuropathies may be increased during salat movements. Head injury may be open or closed, focal or diffuse. Focal head injury is usually due to a hematoma (epidural, subdural, intra-cerebral). Post concussion syndrome is a form of diffuse head injury. Head injury may be associated with paralysis, impaired consciousness, or loss of sensation. Salat and hajj obligations may be affected depending on the extent of injury. Vestibular disturbances make standing up in salat and tawaaf in hajj difficult without support. Brain tumors, both benign and malignant, have pressure effects. The symptoms of increased intra-cranial pressure are: headache, nausea, vomiting, personality changes, and loss of consciousness. They affect salat, hajj, marriage contracts, and judicial proceedings depending on the severity. Each case should be assessed on its own merits.

 

E. OTHERS

Aphasia and dysphasia affect conclusion of marriage contracts, witnessing in courts of law, and public leadership duties. Brain infections may manifest as viral or bacterial meningitis complicated by brain abscesses, cysticercosis, AIDS etc. They have effects of consciousness, sensory, and motor function. The mental clouding that results affects salat, saum, hajj, and witnessing in court. Spinal cord injuries may lead to quadriplegia and paraplegia. Salat movements are restricted in paraplegia and quadriplegia. Hajj is possible if a vehicle is used to carry the pilgrim.

Professor Omar Hasan Kasule Sr. January 2001