1. Obsessive compulsive disorder
and religiosity
Dr. Syed Faheem Shams
Post graduate student
Dept. of Psychiatry, BSMMU

2. Objectives
• Understand religiosity
• When it is OCD?
• Relation of OCD and religiosity
• Evidence based discussion
• Scrupulosity
• Management

3. Case scenario
• A 35-year-old female from Rangamati was raised as a nonpracticing
hindu, but became a Muslim about 10 years ago after marrying a
muslim guy.The first five months of her born-anew life were blissful.
Then she became increasingly scrupulous. She used to retreat into
her room for hours at a time, committing to word-for-word memory
about Quran
• 'Do you really think I'm saved?' She probably ask me that 10 times a
day," says her husband. "I'd get frustrated. I felt like a broken record
answering her questions.“
• "It became a huge tormenting thing for me," she says. "I started
fearing I was never converted or saved. I would have blasphemous
thoughts, cursing God in my mind."

5. http://www.ocduk.org/types-ocd

7. What is religion?
Religion is defined as ‘the belief in and worship of a
superhuman controlling power, especially a personal God
or Gods’
(Oxford English Dictionary, 2006)

9. Ways to measure religiosity
 Religiousness Screening Questionnaire
 The Penn Inventory of Scrupulosity (PIOS)

10. Is there a link between religiosity
and OCD symptomatology?

11. Religious perspectives

12. • Muslims - washing is known as Wudu and is a form of ritual
ablution. If a mistake is made, then the whole process must
be begun again
Faizan e Islam (2010). How to perform Wudu. Available at:
http://www.faizaneislam.org/islam/how_to_perform_wudu.shtml
This procedure display remarkable similarity to the
ritualistic compulsive acts which characterize OCD

13. • Christians may believe that their own private
thoughts are equivalent to physical actions. This
concept is known as moral thought-action fusion
(moral TAF) and is thought to have originated
from the Sermon on the Mount where Jesus said:
‘Ye have heard it was said by them of old time, Thou
shalt not commit adultery: But I say unto you, that
whosoever looketh on a woman to lust after her
hath committed adultery with her already in his
heart’ (Matthew 5: 27-28, King James Version)

14. • Judaism, especially ultra-orthodox sects, requires
that the faithful live by an extensive list of laws
which govern all aspects of life as laid out in the
Shulchan Aruch (Karo, 1565 cited in Hermesh et al., 2003 p.201)
• If laws are not adhered to or not followed
completely then obligations must be repeated until
the law is fulfilled

16. Scrupulosity

17. John Moore (shown c.
1691–1703) was the
first to describe the
disorder, calling it
"religious melancholy"

18. Scrupulosity is a psychological disorder
characterized by pathological guilt about moral or
religious issues. It is personally distressing,
objectively dysfunctional, and often accompanied by
significant impairment in social functioning
Miller CH, Hedges DW. Scrupulosity disorder: an overview and introductory
analysis. J Anxiety Disord. 2008;22(6):1042–58.

19. It is a type of OCD in which individuals’ obsessions
focus on religious or moral fears, such as sin, divine
retribution, and the implications of being an evil or
bad person
(Ciarrocchi, 1995; Purdon & Clark, 2005).

20. Scrupulosity is a recognized diagnostic criterion for
obsessive–compulsive personality disorder
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 4th, text revision (DSM-IV-TR) ed. 2000

21. Several historical and religious figures suffered
from doubts of sin, and expressed their pains
Ignatius of Loyola, founder of the Jesuits, wrote
"After I have trodden upon a cross formed by two
straws ... there comes to me from without a thought
that I have sinned ... this is probably a scruple and
temptation suggested by the enemy."
van Megen HJGM, den Boer-Wolters D, Verhagen PJ. Obsessive compulsive disorder and religion: a reconnaissance.
In: Verhagen P, Van Praag HM, López-Ibor JJ Jr, Cox J, Moussaoui D, editors. Religion and Psychiatry: Beyond
Boundaries. Wiley; 2010.

22. Alphonsus Liguori, the Redemptorists' founder,
wrote of it as "groundless fear of sinning that arises
from 'erroneous ideas”
Taylor CZ. Religious addiction: obsession with
spirituality. Pastoral Psych. 2002;50(4):291–315

23. link between religiosity and OCD
symptomatology?

24. The putative link between religion and OCD was first
put forward by Freud
Obsessional neurosis as an ‘individual religion’ and
religion as ‘a universal obsessional neurosis’

25. Religious patients are more likely to complain of
religious symptoms of OCD. This implies that religiosity
may have an impact on OCD via symptomatology
Steketee, G., Quay, S. and White, K. (1991), Religion and OCD
patients. Journal of Anxiety Disorders, 5(4): 359-367.
Greenberg, D. and Shefler, G. (2002), Obsessive compulsive
disorder in ultraorthodox Jewish patients: A comparison on
religious and non-religious symptoms. Psychology and
Psychotherapy: Theory, Research and Practice, 75(2): 123-
130(8)

26. Highly religious Turkish Muslims reported increased
intensity of OCD symptoms and more concerns
surrounding thoughts
Yorulmaz, O., Gencoz, T. and Woody, S. (2009), OCD cognitions and
symptoms in different religious contexts. Journal of Anxiety Disorders, 23(3)

27. Highly religious (HR) group scored higher than the
Lower religious (LR) group on key features of moral
TAF over importance of thoughts and responsibility.
In addition, OCD symptoms were found to be
related to control of thoughts and over importance
of thoughts in religious subjects. As such, it seems
that religious individuals are more at risk
Sica, C., Novara, C. and Sanavio, E. (2002), Religiousness and obsessive compulsive
cognitions and symptoms in an Italian population. Behaviour Research
and Therapy, 40(7): 813-823.

28. Evidence against a link between
religiosity and OCD
Religiosity and obsessive-compulsive symptoms in a
group of Iranian students and found no link between
religiosity and OCD
No relation
Assarian, F., Biqam, H., Asqarnejad, A. (2006), An epidemiological study of
obsessive-compulsive disorder among high school students and its relationship with
religious attitudes. Archives of Iranian Medicine, 9(2):104-107.
Lewis, C. A. (1994) Religiosity and obsessionality: the relationship
between Freud's 'religious practices.' Journal of Psychology, 128, 189-196
Siev, J. and Cohen, A. (2007), Is thought-action fusion related to religiosity?
Differences between Christians and Jews. Behaviour Research and Theory, 45(4):
829-837.

29. No difference was found between people
with OCD and other anxiety disorders in
terms of religiosity, although among those
with OCD, religiosity was correlated with
symptom severity
Steketee, G., Quay, S., &White, K. (1991). Religion and guilt in OCD patients.
Journal of Anxiety Disorders, 5, 359–367.
(Canterino, Huppert, Cahill, & Foa, 2006).

31. Management

32. Don’t do
If religion is conceptualized as causing OCD, the
therapist may think that the patient’s religious faith
must be controlled or reduced to support treatment
Purdon, C., & Clark, D. A. (2005). Overcoming obsessive thoughts: How to gain control of your
OCD. Oakland, CA: New Harbinger Press.

33. Don’t do
If the therapist conveys that the patient’s
religious beliefs or community support the
pathology, then the therapist may adopt a
disadvantageous stance toward the patient
that can undermine trust and empathy, and
lead to conflict

34. Do
Understanding that OCD is not caused by religious
adherence, but rather that such adherence can
influence how OCD manifests in religious patients

35. Psychological management

36. • The goal of EX/RP is to weaken the psychological
links between obsessions and increased anxiety,
and compulsions and decreased anxiety
• Patients learn to tolerate their anxiety and that it
will subside even without ritualizing, and these
lessons ultimately reduce anxious reactions

37. ERP is not appropriate for a man obsessed by
feelings that God has rejected and is punishing him
Cognitive therapy

38. Case scenario
• A 35-year-old female from Rangamati was raised a nonpracticing
hindu, but became a Muslim about 10 years ago after marriage with a
muslim guy.The first five months of her born-anew life were blissful.
Then she became increasingly scrupulous. She used to retreat into
her room for hours at a time, committing to word-for-word memory
about quran
• 'Do you really think I'm saved?' She probably ask me that 10 times a
day," says her husband. "I'd get frustrated. I felt like a broken record
answering her questions.“
• "It became a huge tormenting thing for me," she says. "I started
fearing I was never converted or saved. I would have blasphemous
thoughts, cursing God in my mind."

39. In this case, she cannot engage in vivo exposures that violate
religious law (e.g., purposefully offending God through
behaviors that are forbidden)
The therapist must work with the patient to understand the
limits of religiously acceptable behavior, and create situations
in which she can violate OCD law, but not religious law. This
requires understanding, creativity, and tolerance

40. • Cognitive Behavioural Therapy (CBT) has been
shown to be effective in the treatment
• CBT known as ‘guided prayer repetition’ which, it is
claimed, is a more acceptable and successful form
of therapy for religious patients. It will be
interesting to determine its use and effectiveness
on a wider scale
Bonchek, A. and Greenberg, D. (2009), Compulsive prayer and its management. Journal of
Clinical Psychology, 65: 396–405.

41. Take away message
• Whilst the question of whether religiosity causes
or predisposes to OCD is still unresolved
• Studies that directly investigate the relationship
between religiosity and OCD fail to demonstrate
an association between religiosity and the
development of clinically significant OCD
symptoms

42. Starting in the 20th century, individuals with
scrupulosity in the U.S. and Britain increasingly
began looking to psychiatrists, rather than to
religious advisors, for help with their disorder
Bourke J. Divine madness: the dilemma of religious scruples in twentieth-century America and
Britain. J Soc Hist. 2009;42(3):581–603

43. To deal with this, practices might consider courses
to educate medical staff. GPs may consider
contacting religious leaders, with the patient’s
consent, in order to improve understanding of the
case
(as suggested in section 10.1.4 of the 2007 NICE
guidelines for OCD).

44. Objectives
• Understand religiosity
• When it is OCD?
• Relation of OCD and religiosity
• Evidence based discussion
• Scrupulosity
• Management