Religiosity, Spirituality, and OCD-Related Symptoms in Clinical & Nonclinical Samples

Scrupulosity OCD, or just Scrupulosity, is a subtype of Obsessive Compulsive Disorder (OCD) characterized by pathological guilt or personal responsibility associated with moral issues or religious themes, which can be displayed and conceptualized in several ways.

Individuals experiencing scrupulosity will experience intrusive, unwanted thoughts, images, or urges about violating their religious, moral, or ethical beliefs.

This might include a fear of offending God, committing a sin, praying incorrectly, misinterpreting religious teachings, or going to the “wrong” place of worship. 

Henderson, L. C., Stewart, K. E., Koerner, N., Rowa, K., McCabe, R. E., & Antony, M. M. (2022). Religiosity, spirituality, and obsessive-compulsive disorder-related symptoms in clinical and nonclinical samples. Psychology of Religion and Spirituality, 14(2), 208–221. https://doi.org/10.1037/rel0000397

Key Points

1. Scrupulosity (excessive religious obsessions and compulsions) is positively associated with obsessional thinking in both nonclinical and clinical OCD samples.
2. Religious fundamentalism has a trivial relationship with obsessional thinking in nonclinical samples and no relationship in clinical OCD samples.
3. Scrupulosity is positively related to religious crisis (feelings of alienation from God and religious community) in both nonclinical and clinical samples.
4. Spirituality (especially the belief in an ordered universe and human connectedness) moderates the relationship between religiosity and moral thought-action fusion in clinical OCD samples.
5. Spirituality does not meaningfully moderate the relationship between religiosity and scrupulosity.
6. Spirituality (especially the belief in an ordered universe and human connectedness) moderates the relationship between religiosity and religious fundamentalism in clinical OCD samples.

Rationale

Past research on the relationship between religiosity, spirituality and OCD has been mixed, with some studies finding a positive association (e.g., Steketee et al., 1991) and others finding no relationship or even a negative relationship (e.g., Dèttore et al., 2017).

These inconsistent findings may be partly explained by limitations in measurement of religiosity and spirituality constructs and a predominant reliance on student samples (Siev et al., 2017).

The current study aimed to clarify these relationships using multidimensional measures across a wide range of religious affiliations in both nonclinical and clinical OCD samples.

Understanding these relationships has implications for identifying risk factors for OCD as well as potential treatment targets.

Method

The nonclinical sample included 746 participants recruited from a university and online sources. The clinical sample included 24 participants with a diagnosis of OCD recruited from an anxiety clinic.

Materials

• Diagnostic interviews (SCID-IV or MINI) to confirm OCD diagnosis in clinical sample
• Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to assess OCD symptom severity
• Obsessive-Compulsive Inventory-Revised (OCI-R) to assess OCD symptoms
• Thought-Action Fusion (TAF) Scale to assess fusion beliefs
• Penn Inventory of Scrupulosity (PIOS) to assess religious obsessions/compulsions
• Assessment of Spiritual and Religious Sentiments (ASPIRES) scale to assess spirituality and religiosity
• Revised Religious Fundamentalism Scale to assess religious fundamentalism

Statistical analysis included correlational analyses to test study hypotheses and moderation analyses to test conditional effects.

Sample

The nonclinical sample included 746 participants aged 17-65 years old. Most were female, white or South/East Asian, and endorsed a variety of religious affiliations including Catholicism, Hinduism, Islam, Judaism, and no religion.

The clinical sample included 24 participants aged 18-61 years with a principal DSM-5 diagnosis of OCD. Most were male and white. Comorbid diagnoses were permitted.

Results

The study found a robust, positive correlation between scrupulosity, defined as pathological fear of sin and divine punishment, and obsessional thinking in participants both with and without a diagnosis of OCD.

Specifically, the degree to which individuals experienced intrusive, unwanted thoughts related to religion and morality was closely linked to their tendency for obsessive rumination and thought suppression attempts. As religious obsessions intensified, so too did urges to mentally review one’s moral purity and actions excessively.

This suggests religious obsessions may directly contribute to broader OCD cognitive patterns like obsessionality.

While the study found that scrupulosity (defined as religious obsessions and compulsions related to excessive concern over sin and God’s punishment) has a robust positive correlation with OCD symptoms, measures of broader religiosity and spirituality did not.

Most indicators of typical religious practices and spiritual experiences did not correlate with heightened OCD symptoms.

For example, religious attendance, prayer frequency, and self-rated religiousness showed trivial or non-significant relationships with obsessional thinking and compulsive behaviors both in nonclinical samples and samples diagnosed with OCD.

Additional findings

• Likelihood thought-action fusion positively correlated with religious crisis in both samples

Insight

This study clarifies the relationship between religiosity, spirituality and OCD using psychometrically-sound multidimensional measures across diverse religious groups. Results suggest scrupulosity, but not overall religiosity/spirituality, is associated with OCD symptoms.

However, those experiencing religious obsessions may also suffer from religious crisis. For religious individuals with OCD, enhancing spirituality may buffer relationships between religiosity and OCD-relevant cognitive distortions like thought-action fusion and fundamentalism.

Clinically, this highlights potential benefits of incorporating spirituality-focused consultation with religious authorities into CBT.

Strengths

• Used reliable, valid measures clearly differentiating religiosity and spirituality
• Included diverse religious affiliations rarely studied in OCD research
• Compared clinical and nonclinical samples

Limitations

• Correlational design limits causal conclusions
• Samples not fully representative (mostly female, moderately religious)
• Small clinical sample size for moderation analyses

Clinical Implications

These results align with other recent findings that religiosity itself does not constitute a risk factor for developing clinical OCD.

Rather, when religious OCD manifests it takes on a scrupulous flavor, centered around excessive doubt and guilt regarding morality and God’s perception. Whether religious involvement fuels these content-specific obsessions for some subgroups, or they originate from mental rituals gone awry, requires further study.

Regardless, the current study clearly demonstrates the specificity of the link between OCD symptoms and scrupulosity, rather than religion and spirituality at large. This has implications for conceptualizing religion’s role in OCD’s pathology through a narrower lens.

Support for bidirectional relationships means OCD symptoms may negatively impact spirituality. Collaborative treatment incorporating religious authorities merits further study.

References

Primary reference

Henderson, L. C., Stewart, K. E., Koerner, N., Rowa, K., McCabe, R. E., & Antony, M. M. (2022). Religiosity, spirituality, and obsessive-compulsive disorder-related symptoms in clinical and nonclinical samples. Psychology of Religion and Spirituality, 14(2), 208–221. https://doi.org/10.1037/rel0000397

Other references

Siev, J., Huppert, J. D., & Zuckerman, S. E. (2017). Understanding and treating scrupulosity. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (Vol. 2, pp. 527–546). Hoboken, NJ: Wiley and Sons. http://dx.doi.org/10.1002/9781118890233.ch29

Dèttore, D., Berardi, D., & Pozza, A. (2017). Religious affiliation and obsessive cognitions and symptoms: A comparison between Jews, Christians, and Muslims in nonclinical groups in Italy. Psychology of Religion and Spirituality, 9, 348–357. http://dx.doi.org/10.1037/rel0000078

Steketee, G., Quay, S., & White, K. (1991). Religion and guilt in OCD patients. Journal of Anxiety Disorders, 5, 359–367. http://dx.doi.org/10.1016/0887-6185(91)90035-R

Keep Learning

1. How might clinicians adapt CBT protocols to address religious crisis and enhance spirituality for religious OCD clients? What challenges might this present?
2. What longitudinal or experimental designs could help establish causality between OCD symptoms, religiosity, spirituality and related cognitive distortions?
3. How might future research better capture the experience of underrepresented religious groups in studying OCD? What barriers exist to recruiting diverse OCD samples?
4. Could enhancing spirituality benefit non-religious individuals with OCD? What cognitive mechanisms might connect spirituality and OCD symptoms?
5. Beyond consultation with religious authorities, how else might clinicians collaborate with faith communities to support OCD treatment and recovery?