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journal on OCD and religiosity, dr. ponchanon



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  • 1. WELCOM E Dr.Panchanan Acharjee, MD(Psychiatry), Phase-A Resident, B.S.M.M.U.
  • 2. SOURCE OF THE JOURNAL: Journal : Journal of Clinical Psychology Volume : 67(12) Pages : 1188-1196 Published on : 21st April, 2012. Copyright : Wiley Periodicals, Inc.
  • 3. PARTICULARS OF THE JOURNAL: Type of article: - Original article Title of the article: - Obsessive-Compulsive Disorder With Predominantly Scrupulous Symptoms: Clinical and Religious Characteristics.
  • 4. AUTHORS OF THE JOURNAL:  Jedidiah Siev,  Lee Baer, and  William E. Minichiello. From:  Massachusetts General Hospital, and  Harvard Medical School.
  • 5. RATIONALE:  Scrupulosity is a relatively common but understudied subtype of OCD which is difficult to treat and frequently disabling.  The presence of religious obsessions might predict poor treatment outcome in treatment of OCD. (Alonso et al., 2001; Ferra˜o et al., 2006; Mataix-Cols,Marks, Greist, Kobak, & Baer, 2002; Rufer, Grothusen, MaX, Peter, & Hand, 2005),
  • 6. RATIONALE:  There is reason to suspect that, individuals with religious obsessions are under-represented in clinical trials. (Ball, Baer, & Otto, 1996).
  • 7. INTRODUCTION:  Obsessive-compulsive disorder (OCD) is a prevalent and chronic disorder that affects approximately 2.5% of the population. (Karno, Golding, Sorenson, & Burnam, 1988; Weissman, Bland, Canino, & Greenwald, 1994)  OCD is associated with marked distress and severe impairment in functioning across multiple domains. (Bobes et al., 2001; Koran, 2000).
  • 8. INTRODUCTION:  The earliest descriptions of 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. (David Greenberg & Jonathan D. Huppert, Curr Psychiatry Rep (2010) 12:282–289).
  • 9. INTRODUCTION:  Scrupulosity is a common subtype of OCD characterized by religious or moral fears. In Western cultures, 10%–33% of individuals with OCD have religious obsessions (Eisen et al., 1999; Mataix-Cols et al., 2002), and such fears represent primary symptoms in 5%–6%. (Foa & Kozak, 1995; Tolin, Abramowitz, Kozak, & Foa, 2001). In some cultures, as many as, 40%–60% of individuals with OCD experience religious obsessions. (Tek & Ulug, 2001)
  • 10. SOME KEY WORDS:  Obsessive-Compulsive Disorder (OCD): It is a debilitating disorder marked by two distinct phenomena: recurrent, disturbing, intrusive thoughts (obsessions) and overt repetitive behaviors or mental acts (compulsions) performed to reduce distress caused by obsessions. (American Psychiatric Association 2005).
  • 11. SOME KEY WORDS:  OCD…… The most common types of obsessions are contamination, need for symmetry, religious, aggressive, sexual, precision and somatic obsessions, and the most common compulsions are checking, washing, hoarding, and counting compulsions. (Bloch et al.2008).
  • 12. SOME KEY WORDS:  OCD…… It is diagnosed when the obsessions or compulsions cause marked distress, are recognized at least at some point as being excessive and/or irrational, are time consuming, and significantly interfere with the person’s functioning. (American Psychiatric Association 2005).
  • 13. SOME KEY WORDS:  Religious obsessions: Common religious obsessions include fears that one has committed sins (or will do so), intrusive mental images of a sacrilegious or blasphemous nature, and fears that one will be punished by God or will go to Hell because of these thoughts. (Abramowitz et al.2002; Okasha et al. 1994).
  • 14. SOME KEY WORDS:  Religious compulsions: Common religious compulsions include excessive praying, ritualistic cleansing procedures, excessive attention to minor details of religious tradition, and seeking reassurance from religious leaders or loved ones about religious matters. (Abramowitz et al.2002; Okasha et al. 1994).
  • 15. SOME KEY WORDS:  Scrupulosity: It is a psychological disorder characterized by pathological guilt about moral or religious issues. Derived from the Latin scrupulum, a sharp stone, implying a stabbing pain on the conscience. It is typically conceptualized as a moral or religious form of OCD.
  • 16. SOME KEY WORDS: Scrupulosity…… It is the modern-day medical diagnosis that corresponds to a traditional use of the term scruples in a religious context, to mean obsessive concern with one's own sins and compulsive performance of religious devotion.
  • 17. SOME KEY WORDS: Scrupulosity…… It was first described as a disorder in 1691, by John Moore, who called it "religious melancholy" and said it made people fear that, what they do, is so defective and unfit to be presented unto God, that He will not accept it. ( Scrupulous fears are usually connected in some way to sinning or being an immoral person, although specific themes vary by religion.
  • 18. OBJECTIVE:  Treatment-seeking behavior and perceived treatment gains among scrupulous and non-scrupulous OCD.  Perceptions of symptoms, as interfering with or facilitating one’s relationship with God or religious observance; among individuals with scrupulous and non-scrupulous OCD.  Conceptions of God among scrupulous individuals.
  • 19. DESIGN & METHOD:  Participants: Any individual, 18 yrs or older, who reported to have diagnosed as OCD.  An internet-based research study via advertisements on the website ( and in the newsletter for the International OCD Foundation; at the time named the Obsessive Compulsive Foundation.
  • 20. DESIGN & METHOD:  Scrupulous and non-scrupulous participants were recruited separately.  Advertisements for scrupulous participants solicited individuals; whose scrupulosity interfered with their lives by answering ‘‘questions about your problems with scrupulosity.’’
  • 21. DESIGN & METHOD:  Advertisements for non-scrupulous participants solicited individuals; - with ‘‘primary obsessions and compulsions not focused on religion, spirituality, or morality’’; - for a study about ‘‘how non scrupulous OCD (i.e., OCD not related to religion, spirituality, or morality) might relate to or impact your experience of spirituality or religion.’’
  • 22. DESIGN & METHOD:  Sample size: At the beginning At the end Duration Scrupulous 103 72 February 2009 to June 2009 Non-scrupulous 100 75 June 2009 to September 2009
  • 23. DESIGN & METHOD:  Exclusion Criteria: - When question raised about the primary diagnosis as OCD, after inspecting their primary obsessional fear. - Where missing was >20% of the items on either of the symptom measures in Obsessive Compulsive Inventory – Revised [OCI-R] and Penn Inventory of Scrupulosity scales. 31 0f scrupulosity & 16 of non-scrupulous were excluded.
  • 24. DESIGN & METHOD:  Scales : Obsessive-Compulsive Inventory – Revised (OCI-R) : An 18-item self-report measure of OCD symptoms with adequate psychometric properties in clinical and nonclinical samples (Foa et al.; 2004; Huppert,Walther et al., 2007). The OCI-R yields a total score and six subscales that measure symptoms of washing, checking, obsessing, ordering, neutralizing, and hoarding.
  • 25. DESIGN & METHOD: Scales : Penn Inventory of Scrupulosity (PIOS) : An 19-item self-report measure of religious OCD symptoms. It has adequate psychometric properties in nonclinical samples (Abramowitz et al.; Olatunji et al.,2007) and has been used to measure scrupulosity in clinical participants (Nelson et al., 2006).
  • 26. DESIGN & METHOD:  Concepts of God: Participants rated how much they agree, ranging from 1 (strongly disagree) to 5 (strongly agree), that each of 13 words describes their conception of God. (A. B. Cohen, personal communication, December 31, 2008) The results of a principal components analysis with Varimax rotation revealed two factors: positive and negative concepts of God.
  • 27. DESIGN & METHOD: Concepts of God: The positive factor comprised six words (peaceful, kind, comforting, gentle, compassionate, and loving). The negative factor comprised six words (punishing, fearsome, terrifying, jealous, angry, and vengeful). One item (harsh) cross-loaded on both factors and was eliminated.
  • 28. DESIGN & METHOD: Procedure: - Subjects went to research website ( to participate by clicking ‘‘continue’’ button, which took them to the SurveyMonkeyTM website, where they anonymously completed the surveys and questionnaires. - All responses were stored unidentified, and were downloaded at the conclusion of the study for data analysis using SPSS.
  • 29. RESULTS: The groups did not differ in age, gender, race, ethnicity, education.
  • 30. RESULTS: The groups did not differ significantly in the percentage who reported having no religious affiliation. (18% versus 24%)
  • 31. RESULTS: The groups showed high contrast (70% versus 32%) while reporting symptoms interfered on relationship with God.
  • 32. RESULTS: Even 20% of scrupulous participants, believed that their symptoms helped their religious experience.
  • 33. RESULTS:  No significant difference in overall symptom severity, as measured by the OCI-R total score. But, the scrupulous group scored higher on the PIOS.
  • 34. RESULTS:  Rates of pastoral counseling is higher (42% vs 12%) among group-A; while group-B had a higher rate for prescribing a medication, (66% versus 85%).
  • 35. RESULTS:  Among individuals with scrupulosity, severity of scrupulous symptoms (PIOS score) was moderately and positively associated with a more negative concept of God (r= 5.35, p=5.002), and unrelated to positive concept of God (r = -.05, p = .66).  Comparison did not made about concepts of God between the two groups; as they differed in level of religiosity.
  • 36. SUMMARY OF RESULTS:  Compared with the non-scrupulous group, the scrupulous group was - more religious, - more likely to seek pastoral counseling, - less likely to seek medication treatment, & - more likely to report that symptoms interfered with their religious experience.
  • 37. SUMMARY OF RESULTS:  The groups did not differ on demographic variables or overall OCD severity.  Scrupulous individuals with a more negative concept of God experienced more severe symptoms, whereas a positive description of God was unrelated to severity of scrupulosity in this group.  Nearly one in five scrupulous participants reported no religious affiliation.
  • 38. RECOMMENDATIONS:  Scrupulous individuals have unique treatment-seeking preferences. Given the relatively large number of scrupulous patients seeking pastoral counseling, the type and quality of pastoral counseling is deserving of further study. Again, focusing on the religious costs and benefits of scrupulous rituals might have clinical utility.
  • 39. RECOMMENDATIONS:  Almost one in five scrupulous participants reported no religious affiliation, which might reflect those who have a heightened or rigid sense of right and wrong (intrinsic morality) but do not identify with a particular religion. This ‘‘secular scrupulosity’’ is a form of scrupulosity that clinicians encounter less frequently and one that merits further research.
  • 40. RECOMMENDATIONS:  Scrupulous individuals with a more negative concept of God experienced more severe symptoms. Future research is necessary to evaluate whether addressing such concepts can improve treatment outcome.  Majority of scrupulous participants had been prescribed medications, but the percentage was significantly smaller than among non-scrupulous OCD participants. Further research is necessary to elucidate this difference.
  • 41. LIMITATIONS  Sample size was comparatively poor.  Participants were not administered a clinical interview to confirm diagnostic status.  It is possible that some participants received inadequate CBT and this influenced their perceptions of benefits from CBT and whether their symptoms facilitate their relationship with God.
  • 42. SOME RELATED FINDINGS:  Scrupulosity and Obsessive Compulsive Disorder: The Cognitive Perspective in Islamic Sources; Lutfullah Besiroglu• Sitki Karaca• Ibrahim Keskin; ©Springer Science+Business Media, LLC 2012. - Experiencing scruples is a common problem among Muslims and the people suffering from scruples are usually inclined to seek help from religious advisors. - The goal of treatment should be to help the patient realize their own goals, often including healthier religious functioning (e.g., praying within a reasonable time interval, avoiding major sins).
  • 43. SOME RELATED FINDINGS:  Scrupulosity: A Unique Subtype of Obsessive- Compulsive Disorder; David Greenberg & Jonathan D. Huppert; Current Psychiatry Report (2010) 12:282–289. - Individuals with OCD in general have a tendency to treat thoughts as equivalent to actions - known as thought-action fusion [TAF]. - TAF is divided into two main categories: 1) the belief that the thought is likely to increase the probability of an event to occur, and 2) the immorality of having the thought. - It does not appear that religion causes OCD, but rather that it influences its manifestation such that religious people are more likely to have religious symptoms.
  • 44. COMMENTS OF THE PRESENTATOR:  Religion plays a major role in almost every sphere of life of peoples in our sub-continent. And so, scrupulosity is a more common finding.  We all should have a clear conception about the difference between normal religious behavior and scrupulosity.
  • 45. COMMENTS OF THE PRESENTATOR:  Positive thinking, like --- - religion is mainly a philosophy, not merely some clusters of rituals, - confusions, negative thoughts etc are very common in early religious life. - the Almighty is more kind, compassionate, and loving than punishing and not at all fearsome, terrifying, angry, or vengeful one. --- about the religion and the Almighty, may help us against scrupulosity.
  • 46. THANK YOU