Skip to main content Accessibility help

Scrupulosity, Religious Affiliation and Symptom Presentation in Obsessive Compulsive Disorder

  • Jennifer L. Buchholz (a1), Jonathan S. Abramowitz (a1), Bradley C. Riemann (a2), Lillian Reuman (a1), Shannon M. Blakey (a1), Rachel C. Leonard (a2) and Katherine A. Thompson (a1)...


Background: Scrupulosity is a common yet understudied presentation of obsessive compulsive disorder (OCD) that is characterized by obsessions and compulsions focused on religion. Despite the clinical relevance of scrupulosity to some presentations of OCD, little is known about the association between scrupulosity and symptom severity across religious groups. Aims: The present study examined the relationship between (a) religious affiliation and OCD symptoms, (b) religious affiliation and scrupulosity, and (c) scrupulosity and OCD symptoms across religious affiliations. Method: One-way ANOVAs, Pearson correlations and regression-based moderation analyses were conducted to evaluate these relationships in 180 treatment-seeking adults with OCD who completed measures of scrupulosity and OCD symptom severity. Results: Scrupulosity, but not OCD symptoms in general, differed across religious affiliations. Individuals who identified as Catholic reported the highest level of scrupulosity relative to individuals who identified as Protestant, Jewish or having no religion. Scrupulosity was associated with OCD symptom severity globally and across symptom dimensions, and the magnitude of these relationships differed by religious affiliation. Conclusions: Findings are discussed in terms of the dimensionality of scrupulosity, need for further assessment instruments, implications for assessment and intervention, and the consideration of religious identity in treatment.


Corresponding author

Correspondence to Jennifer Buchholz, University of North Carolina at Chapel Hill, Department of Psychology and Neuroscience, Chapel Hill, NC 27599-3270, USA. E-mail:


Hide All
Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D. et al. (2010). Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive Scale. Psychological Assessment, 22, 180.
Abramowitz, J. S., Huppert, J. D., Cohen, A. B., Tolin, D. F. and Cahill, S. P. (2002). Religious obsessions and compulsions in a non-clinical sample: The Penn Inventory of Scrupulosity (PIOS). Behaviour Research and Therapy, 40, 824838.
Abramowitz, J. S. and Jacoby, R. J. (2014). Scrupulosity: a cognitive-behavioral analysis and implications for treatment. Journal of Obsessive-Compulsive and Related Disorders, 3, 140–149.
Antony, M. M., Downie, F. and Swinson, R. P. (1998). Diagnostic issues and epidemiology in obsessive–compulsive disorder. In Swinson, R. P., Antony, M. M., Rachman, S. J. and Richter, M. A. (eds), Obsessive-Compulsive Disorder: Theory, Research and Treatment. (pp. 332). New York, NY, US: Guilford Press.
Berman, N. C., Abramowitz, J. S., Pardue, C. M. and Wheaton, M. G. (2010). The relationship between religion and thought–action fusion: use of an in vivo paradigm. Behaviour Research and Therapy, 48, 670674.
Cohen, A. B. and Rozin, P. (2001). Religion and the morality of mentality. Journal of Personality and Social Psychology, 81, 697.
Foa, E. B. and Kozak, M. J. (1995). DSM-IV field trial: obsessive-compulsive disorder. The American Journal of Psychiatry, 152, 90.
Greenberg, D. (1984). Are religious compulsions religious or compulsive: a phenomenological study. American Journal of Psychotherapy, 38, 524.
Greenberg, D. and Huppert, J. D. (2010). Scrupulosity: a unique subtype of obsessive-compulsive disorder. Current Psychiatry Reports, 12, 282289.
Greenberg, D. and Shefler, G. (2002). Obsessive compulsive disorder in ultra-orthodox Jewish patients: a comparison of religious and non-religious symptoms. Psychology and Psychotherapy: Theory, Research and Practice, 75, 123130.
Hayes, A. F. (2013). Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York: Guilford Press.
Hayes, A. F. and Montoya, A. K. (2017). A tutorial on testing, visualizing, and probing an interaction involving a multicategorical variable in linear regression analysis. Communication Methods and Measures, 11, 130.
Huppert, J. D. and Fradkin, I. (2016). Validation of the Penn Inventory of Scrupulosity (PIOS) in scrupulous and nonscrupulous patients: revision of factor structure and psychometrics. Psychological Assessment, 28, 639.
Huppert, J. D. and Siev, J. (2010). Treating scrupulosity in religious individuals using cognitive-behavioral therapy. Cognitive and Behavioral Practice, 17, 382392.
Huppert, J. D., Siev, J. and Kushner, E. S. (2007). When religion and obsessive–compulsive disorder collide: treating scrupulosity in ultra-orthodox Jews. Journal of Clinical Psychology, 63, 925941.
Inozu, M., Clark, D. A. and Karanci, A. N. (2012). Scrupulosity in Islam: a comparison of highly religious Turkish and Canadian samples. Behavior Therapy, 43, 190202.
Kaviani, S., Eskandari, H. and Ebrahimi Ghavam, S. (2015). The relationship between scrupulosity, obsessive-compulsive disorder and its related cognitive styles. Practice in Clinical Psychology, 3, 4760.
Kozak, M. J. and Coles, M. E. (2005). Treatment for OCD: unleashing the power of exposure. In Concepts and Controversies in Obsessive-Compulsive Disorder (pp. 283315). Springer. Retrieved from:
Lee, H.-J. and Kwon, S.-M. (2003). Two different types of obsession: autogenous obsessions and reactive obsessions. Behaviour Research and Therapy, 41, 1129.
Lee, I. A. and Preacher, K. J. (2013). Calculation for the test of the difference between two dependent correlations with one variable in common [computer software]. Available at: (accessed 25 March 2018).
Mataix-Cols, D., Marks, I. M., Greist, J. H., Kobak, K. A. and Baer, L. (2002). Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychotherapy and Psychosomatics, 71, 255262.
McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D. et al. (2004). A critical evaluation of obsessive–compulsive disorder subtypes: symptoms versus mechanisms. Clinical Psychology Review, 24, 283313.
Murray-Swank, A. B., McConnell, K. M. and Pargament, K. I. (2007). Understanding spiritual confession: a review and theoretical synthesis. Mental Health, Religion and Culture, 10, 275291.
Nelson, E. A., Abramowitz, J. S., Whiteside, S. P. and Deacon, B. J. (2006). Scrupulosity in patients with obsessive-compulsive disorder: relationship to clinical and cognitive phenomena. Journal of Anxiety Disorders, 20, 10711086.
Okasha, A. (2004). OCD in Egyptian adolescents: the effect of culture and religion. Psychiatric Times, 21, 15.
Olatunji, B. O., Abramowitz, J. S., Williams, N. L., Connolly, K. M. and Lohr, J. M. (2007). Scrupulosity and obsessive-compulsive symptoms: confirmatory factor analysis and validity of the Penn Inventory of Scrupulosity. Journal of Anxiety Disorders, 21, 771787.
Rachman, S. (1998). A cognitive theory of obsessions: elaborations. Behaviour Research and Therapy, 36, 385401.
Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793802.
Rassin, E. and Koster, E. (2003). The correlation between thought–action fusion and religiosity in a normal sample. Behaviour Research and Therapy, 41, 361368.
Salkovskis, P., Shafran, R., Rachman, S. and Freeston, M. H. (1999). Multiple pathways to inflated responsibility beliefs in obsessional problems: possible origins and implications for therapy and research. Behaviour Research and Therapy, 37, 10551072.
Shafran, R., Thordarson, D. S. and Rachman, S. (1996). Thought-action fusion in obsessive compulsive disorder. Journal of Anxiety Disorders, 10, 379391.
Siev, J., Baer, L. and Minichiello, W. E. (2011a). Obsessive-compulsive disorder with predominantly scrupulous symptoms: clinical and religious characteristics. Journal of Clinical Psychology, 67, 11881196.
Siev, J., Chambless, D. L. and Huppert, J. D. (2010). Moral thought–action fusion and OCD symptoms: the moderating role of religious affiliation. Journal of Anxiety Disorders, 24, 309312.
Siev, J. and Cohen, A. B. (2007). Is thought–action fusion related to religiosity? Differences between Christians and Jews. Behaviour Research and Therapy, 45, 829837.
Siev, J., Steketee, G., Fama, J. M. and Wilhelm, S. (2011b). Cognitive and clinical characteristics of sexual and religious obsessions. Journal of Cognitive Psychotherapy, 25, 167176.
Steiger, J. H. (1980). Tests for comparing elements of a correlation matrix. Psychological Bulletin, 87, 245.
Steketee, G., Frost, R. and Bogart, K. (1996). The Yale-Brown obsessive compulsive scale: interview versus self-report. Behaviour Research and Therapy, 34, 675684.
Tolin, D. F., Abramowitz, J. S., Kozak, M. J. and Foa, E. B. (2001). Fixity of belief, perceptual aberration, and magical ideation in obsessive–compulsive disorder. Journal of Anxiety Disorders, 15, 501510.
Wheaton, M. G., Abramowitz, J. S., Berman, N. C., Riemann, B. C. and Hale, L. R. (2010). The relationship between obsessive beliefs and symptom dimensions in obsessive-compulsive disorder. Behaviour Research and Therapy, 48, 949954.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Behavioural and Cognitive Psychotherapy
  • ISSN: 1352-4658
  • EISSN: 1469-1833
  • URL: /core/journals/behavioural-and-cognitive-psychotherapy
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Scrupulosity, Religious Affiliation and Symptom Presentation in Obsessive Compulsive Disorder

  • Jennifer L. Buchholz (a1), Jonathan S. Abramowitz (a1), Bradley C. Riemann (a2), Lillian Reuman (a1), Shannon M. Blakey (a1), Rachel C. Leonard (a2) and Katherine A. Thompson (a1)...
Submit a response


No Comments have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *