Current Psychiatry Reports

, Volume 12, Issue 4, pp 282–289 | Cite as

Scrupulosity: A Unique Subtype of Obsessive-Compulsive Disorder

Article

Abstract

The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed.

Keywords

Obsessive-compulsive disorder Subtypes Scrupulosity Religion 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Greenberg D, Shefler G: Ultra-Orthodox rabbinic responses to religious obsessive-compulsive disorder. Isr J Psychiatry Relat Sci 2008, 45:183–192.PubMedGoogle Scholar
  2. 2.
    Pitman RK: Obsessive-compulsive disorder in Western history. In Current Insights in Obsessive Compulsive Disorder. Edited by Hollander E, Zohar J, Marazziti D, Oliver B. Chichester, United Kingdom: John Wiley and Sons; 1994:3–11.Google Scholar
  3. 3.
    Ignatius S: Spiritual Exercises of Saint Ignatius of Loyola. Translated by Delmage L. Boston, MA: Daughters of Saint Paul; 1978.Google Scholar
  4. 4.
    Enoch MD, Trethowan W: Uncommon Psychiatric Syndromes. Bristol, United Kingdom: John Wright; 1979.Google Scholar
  5. 5.
    Flecknoe R: Enigmatical characters. In Three Hundred Years of Psychiatry 1535–1860. Edited by Hunter D, Macalpine I. London: Oxford University Press; 1963:116.Google Scholar
  6. 6.
    Cefalu P: The doubting disease: religious scrupulosity and obsessive-compulsive disorder in historical context. J Med Humanit 2010, 31:111–125.CrossRefPubMedGoogle Scholar
  7. 7.
    Berrios GE: Obsessive-compulsive disorder: its conceptual history in France during the 19th century. Compr Psychiatry 1989, 30:283–295.CrossRefPubMedGoogle Scholar
  8. 8.
    Lewis A: Problems of obsessional illness. Proc R Soc Med 1936, 29:325–336.PubMedGoogle Scholar
  9. 9.
    Greenberg D: Are religious compulsions religious or compulsive: a phenomenological study. Am J Psychother 1984, 38:524–532.PubMedGoogle Scholar
  10. 10.
    Greenberg D, Witztum E: The influence of cultural factors on obsessive compulsive disorder: religious symptoms in a religious society. Isr J Psychiatry Relat Sci 1994, 31:211–220.PubMedGoogle Scholar
  11. 11.
    Greenberg D, Shefler G: Obsessive compulsive disorder in ultra-orthodox Jewish patients: a comparison of religious and non-religious symptoms. Psychol Psychother 2002, 75:123–130.CrossRefPubMedGoogle Scholar
  12. 12.
    Shafran R, Rachman S: Thought-action fusion: a review. J Behav Ther Exp Psychiatry 2004, 35:87–107.CrossRefPubMedGoogle Scholar
  13. 13.
    Abramowitz JS, Nelson CA, Rygwall R, et al.: The cognitive mediation of obsessive-compulsive symptoms: a longitudinal study. J Anxiety Disord 2007, 21:91–104.CrossRefPubMedGoogle Scholar
  14. 14.
    •• Miller CH, Hedges DW: Scrupulosity disorder: an overview and introductory analysis. J Anxiety Disord 2008, 22:1042–1058. This is a review of the concept of scrupulosity that proposes that it is distinct from OCD. This is one of the most comprehensive reviews of the topic, although we disagree with most of the analyses and conclusion.CrossRefPubMedGoogle Scholar
  15. 15.
    Cohen AB, Rozin P: Religion and the morality of mentality. J Pers Soc Psychol 2001, 81:697–710.CrossRefPubMedGoogle Scholar
  16. 16.
    Yorulmaz O, Gençöz T, Woody S: OCD cognitions and symptoms in different religious contexts. J Anxiety Disord 2009, 23:401–406.CrossRefPubMedGoogle Scholar
  17. 17.
    •• Siev J, Chambless DL, Huppert JD: Moral thought-action fusion and OCD symptoms: the moderating role of religious affiliation. J Anxiety Disord 2010, 24:309–312. This study reaches the interesting conclusion that TAF, a cognitive concept posited to encourage the development of OCD, is associated with OCD only in religions in which the concept is not normative.CrossRefPubMedGoogle Scholar
  18. 18.
    Siev J, Cohen AB: Is thought-action fusion related to religiosity? Differences between Christians and Jews. Behav Res Ther 2007, 45:829–837.CrossRefPubMedGoogle Scholar
  19. 19.
    Zohar J, Hermesh H: Obsessive-compulsive disorder. Isr J Psychiatry Relat Sci 2008, 45:149–150.PubMedGoogle Scholar
  20. 20.
    Mataix-Cols D, Frost RO, Pertusa A, et al.: Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety 2010 Mar 24 (Epub ahead of print).Google Scholar
  21. 21.
    Greenberg D, Witztum E, Pisante J: Scrupulosity: religious attitudes and clinical presentations. Br J Med Psychol 1987, 60:29–37.PubMedGoogle Scholar
  22. 22.
    Taylor J: The rule of conscience. In Three Hundred Years of Psychiatry 1535–1860. Edited by Hunter D, Macalpine I. London: Oxford University Press; 1963:163–165.Google Scholar
  23. 23.
    Moore J: Of religious melancholy. In Three Hundred Years of Psychiatry 1535–1860. Edited by Hunter D, Macalpine I. London: Oxford University Press; 1963:252–253.Google Scholar
  24. 24.
    Tolin DF, Abramowitz JS, Kozak MJ, et al.: Fixity of belief, perceptual aberration, and magical ideation in obsessive-compulsive disorder. J Anxiety Disord 2001, 15:501–510.CrossRefPubMedGoogle Scholar
  25. 25.
    Diduca D, Joseph S: Schizotypal traits and dimensions of religiosity. Br J Clin Psychol 1997, 36:635–638.PubMedGoogle Scholar
  26. 26.
    White J, Joseph S, Neil A: Religiosity, psychoticism, and schizotypal traits. Pers Individ Dif 1995, 19:847–851.CrossRefGoogle Scholar
  27. 27.
    Alonso P, Menchon JM, Pifarre J, et al.: Long-term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. J Clin Psychiatry 2001, 62:535–540.PubMedGoogle Scholar
  28. 28.
    Fallon BA, Liebowitz MR, Hollander E, et al.: The pharmacotherapy of moral or religious scrupulosity. J Clin Psychiatry 1990, 51:517–521.PubMedGoogle Scholar
  29. 29.
    Abramowitz JS, Franklin ME, Schwartz SA, Furr JM: Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. J Consult Clin Psychol 2003, 71:1049–1057.CrossRefPubMedGoogle Scholar
  30. 30.
    • Huppert JD, Siev J, Kushner ES: When religion and obsessive-compulsive disorder collide: treating scrupulosity in ultra-Orthodox Jews. J Clin Psychol 2007, 63:925–941. This is a guide to effective CBT for scrupulosity in a specific religious population.CrossRefPubMedGoogle Scholar
  31. 31.
    Mataix-Cols D, Marks IM, Greist JH, et al.: Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychother Psychosom 2002, 71:255–262.CrossRefPubMedGoogle Scholar
  32. 32.
    Mahgoub OM, Abdel-Hafeiz HB: Pattern of obsessive-compulsive disorder in eastern Saudi Arabia. Br J Psychiatry 1991, 158:840–842.CrossRefPubMedGoogle Scholar
  33. 33.
    Abramowitz JS, Huppert JD, Cohen AB, et al.: Religious obsessions and compulsions in a non-clinical sample: the Penn Inventory of Scrupulosity (PIOS). Behav Res Ther 2002, 40:825–838.CrossRefPubMedGoogle Scholar
  34. 34.
    Foa EB, Huppert JD, Leiberg S, et al.: The Obsessive-Compulsive Inventory: development and validation of a short version. Psychol Assess 2002, 14:485–496.CrossRefPubMedGoogle Scholar
  35. 35.
    Nelson EA, Abramowitz JS, Whiteside SP, et al.: Scrupulosity in patients with obsessive-compulsive disorder: relationship to clinical and cognitive phenomena. J Anxiety Disord 2006, 20:1071–1086.CrossRefPubMedGoogle Scholar
  36. 36.
    Fineberg NA, Sharma P, Sivakumaran T, et al.: Does obsessive-compulsive personality disorder belong within the obsessive-compulsive spectrum? CNS Spectr 2007, 12:467–482.PubMedGoogle Scholar
  37. 37.
    Rosmarin DH, Pirutinsky S, Siev J: Recognition of scrupulosity and non-religious OCD by Orthodox and non-Orthodox Jews. J Soc Clin Psychol 2010 (in press).Google Scholar
  38. 38.
    •• Huppert JD, Siev JS: Treating scrupulosity in religious individuals using cognitive-behavioral therapy. Cogn Behav Pract 2010 (in press). This is a general guide to CBT with scrupulosity.Google Scholar
  39. 39.
    Sackett DL, Straus SE, Richardson WS, et al.: Evidence-based Medicine: How to Practice and Teach EBM. New York: Churchill Livingstone; 2000.Google Scholar
  40. 40.
    Elliott C, Radomsky AS: Blasphemous obsessions in obsessive-compulsive disorder (OCD): collision or cooperation between psychology and spirituality? Couns Spiritual 2008, 27:51–69.Google Scholar
  41. 41.
    Hepworth M, Simonds LM, Marsh R: Catholic priests’ conceptualisation of scrupulosity: a grounded theory analysis. Ment Health Relig Cult 2010, 13:1–16.CrossRefGoogle Scholar
  42. 42.
    Dowson JH: The phenomenology of severe obsessive-compulsive neurosis. Br J Psychiatry 1977, 131:75–78.CrossRefPubMedGoogle Scholar
  43. 43.
    Stern RS, Cobb J: Phenomenology of obsessive-compulsive neurosis. Br J Psychiatry 1978, 132:233–239.Google Scholar
  44. 44.
    Swedo SE, Rapoport JL, Leonard H, et al.: Obsessive-compulsive disorder in children and adolescents. Clinical phenomenology of 70 consecutive cases. Arch Gen Psychiatry 1989, 46:335–341.PubMedGoogle Scholar
  45. 45.
    Riddle MA, Scahill L, King R, et al.: Obsessive compulsive disorder in children and adolescents: phenomenology and family history. J Am Acad Child Adolesc Psychiatry 1990, 29:766–772.CrossRefPubMedGoogle Scholar
  46. 46.
    Foa EB, Kozak MJ, Goodman WK, et al.: DSM-IV field trial: obsessive-compulsive disorder. Am J Psychiatry 1995, 152:90–96.PubMedGoogle Scholar
  47. 47.
    Eisen JL, Goodman WK, Keller MB, et al.: Patterns of remission and relapse in obsessive-compulsive disorder: a 2-year prospective study. J Clin Psychiatry 1999, 60:346–351.PubMedGoogle Scholar
  48. 48.
    Pinto A, Mancebo MC, Eisen JL, et al.: The Brown Longitudinal Obsessive Compulsive Study: clinical features and symptoms of the sample at intake. J Clin Psychiatry 2006, 67:703–711.CrossRefPubMedGoogle Scholar
  49. 49.
    Garcia AM, Freeman JB, Himle MB, et al.: Phenomenology of early childhood onset obsessive compulsive disorder. J Psychopathol Behav Assess 2009, 31:104–111.CrossRefPubMedGoogle Scholar
  50. 50.
    Chavira DA, Garrido H, Bagnarello M, et al.: A comparative study of obsessive-compulsive disorder in Costa Rica and the United States. Depress Anxiety 2008, 25:609–619.CrossRefPubMedGoogle Scholar
  51. 51.
    Akhtar S, Wig NN, Varma VK, et al.: A phenomenological analysis of symptoms in obsessive-compulsive neurosis. Br J Psychiatry 1975, 127:342–348.CrossRefPubMedGoogle Scholar
  52. 52.
    Khanna S, Channabasavanna SM: Phenomenology of obsessions in obsessive-compulsive neurosis. Psychopathology 1988, 21:12–18.CrossRefPubMedGoogle Scholar
  53. 53.
    Jaisoorya TS, Reddy YC, Srinath S, et al.: Obsessive-compulsive disorder with and without tic disorder: a comparative study from India. CNS Spectr 2008, 13:705–711.PubMedGoogle Scholar
  54. 54.
    Matsunaga H, Maebayashi K, Hayashida K, et al.: Symptom structure in Japanese patients with obsessive-compulsive disorder. Am J Psychiatry 2008, 165:251–253.CrossRefPubMedGoogle Scholar
  55. 55.
    Eğrilmez A, Gülseren L, Gülseren S, et al.: Phenomenology of obsessions in a Turkish series of OCD patients. Psychopathology 1997, 30:106–110.CrossRefPubMedGoogle Scholar
  56. 56.
    Tek C, Ulug B: Religiosity and religious obsessions in obsessive-compulsive disorder. Psychiatry Res 2001, 104:99–108.CrossRefPubMedGoogle Scholar
  57. 57.
    Tükel R, Ertekin E, Batmaz S, et al.: Influence of age of onset on clinical features in obsessive-compulsive disorder. Depress Anxiety 2005, 21:112–117.CrossRefPubMedGoogle Scholar
  58. 58.
    Karadaĝ F, Oguzhanoglu NK, Ozdel O, et al.: OCD symptoms in a sample of Turkish patients: a phenomenological picture. Depress Anxiety 2006, 23:145–152.CrossRefPubMedGoogle Scholar
  59. 59.
    Besiroglu L, Uguz F, Ozbebit O, et al.: Longitudinal assessment of symptom and subtype categories in obsessive-compulsive disorder. Depress Anxiety 2007, 24:461–466.CrossRefPubMedGoogle Scholar
  60. 60.
    Okasha A, Saad A, Khalil AH, et al.: Phenomenology of obsessive-compulsive disorder: a transcultural study. Compr Psychiatry 1994, 35:191–197.CrossRefPubMedGoogle Scholar
  61. 61.
    Shooka A, al-Haddad MK, Raees A: OCD in Bahrain: a phenomenological profile. Int J Soc Psychiatry 1998, 44:147–154.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Herzog HospitalJerusalemIsrael
  2. 2.Department of PsychologyThe Hebrew University of JerusalemJerusalemIsrael

Personalised recommendations