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Abstract
Known as one of the earliest documented mental ailments, religious scrupulosity remains an understudied thematic presentation of obsessive-compulsive disorder (OCD). Early religious scholars documented what was previously known as religious struggles, have been retrospectively reviewed by several psychiatric clinicians. With the advancement of psychopathological research, updated retrospective psychiatric analysis has been conducted regarding early religious writings of what was previously characterized as religious struggles. Research over the past decade has been reviewed herein that discusses etiological factors in the development of religious scrupulosity. These theories include the cognitive behavioral (CB) model of obsessions and the triple vulnerability theory of emotional disorders. Within the triple vulnerability theory of emotional disorders, the specific psychological vulnerability component is discussed as a salient component to the etiology of religious scrupulosity and is a supporting theoretical component to the CB model of obsessions. Future research considerations are provided along with actionable proposition of fostering a collaborative relationship between mental health professionals and Christian church leadership.
Keywords: religious scrupulosity, obsessive-compulsive disorder, psychopathology, developmental psychology, Christianity
Etiology of Religious Scrupulosity: A Discussion
Obsessive-compulsive disorder (OCD) is classified as a psychological ailment that includes the experience of obsessions and / or compulsions (American Psychiatric Association, 2022). Obsessions as identified by the American Psychiatric Association [APA] (2022) are unwanted, intrusive, or disturbing images, thoughts, or urges, whereas compulsions are identified as recurring behaviors or mental activity individuals feel obligated to perform in response to obsessive activity or according to specific rules that require rigorous application. Though OCD is identified as a mental disorder, obsessive thoughts and compulsive behaviors are not inherently psychopathological. Indeed, non-clinical levels of obsessive compulsive (OC) symptoms are ubiquitous within several cultures and subpopulations (Abramowitz et al., 2014b; Berman et al., 2010; Hunter, 2022; Rachman & de Silva, 1978). The phenomenology of non-clinical levels of OC symptoms have been thoroughly studied for decades (Abramowitz et al., 2014b; Berman et al., 2010; Rachman & de Silva, 1978).
Certainly, outlined by Abramowitz et al. (2014b) several studies investigating the phenomenology of OC symptoms, non-clinical participants are considered analogous to individuals diagnosed with clinical levels of OC symptoms. Though non-clinical levels of OC symptoms are ubiquitous (Abramowitz et al., 2014b; Berman et al., 2010; Hunter, 2022; Rachman & de Silva, 1978) levels of OC symptoms that meet diagnostic threshold for a diagnosis of OCD are reported between 1 – 2% (Fawcett et al., 2020; Friedman-Ezra et al., 2024) and 2 – 3% (Abramowitz et al., 2014b) of the population. Clinical levels of OC symptoms are experienced by the presence of excessive obsessions qualified as unwanted, intrusive, and disturbing which cause marked distress, discomfort, or anxiety (Abramowitz & Buchholz, 2020; APA, 2022; Lack, 2023). Further, compulsive behaviors are performed in response to obsessive activity functioning methodology to alleviate distress or anxiety and mitigate negative events or situations from occurring (APA, 2022; Lack, 2023).
OCD Categories and Early Reports of Scrupulosity
The presentation of OCD symptoms spans across life domains but does share homogenous characteristics (Abramowitz et al., 2014b). Studies utilizing cluster analysis have illuminated homogenous characteristics that have led to the development of thematic structures of OCD symptoms (Abramowitz et al., 2014b). Thematic structures include but are not limited to contamination, sexual orientation, suicide, existentialism, harm, scrupulosity, and pedophilia (Lack, 2023). Though thematic structures of OCD have been thoroughly researched, limited research has been conducted exploring the etiology of religious scrupulosity obsessive-compulsive disorder (RS-OCD; Abramowitz et al., 2002; Abramowitz & Jacoby, 2014a).
RS-OCD although understudied (Abramowitz et al., 2002; Abramowitz & Jacoby, 2014a) may be known as one of the first recorded occurrences of what has come to be known as OCD. Early reports of what would be described as clinical levels of OC symptoms come from the historical records of religious scribes (Lack, 2023; Osborn, 2023). A prominent example of historical reports of clinical levels of OC symptoms is described by Osborn (2023) in his retrospective psychiatric analysis of Martin Luther.
Martin Luther popularly known for his role in resisting the Roman Catholic Church’s position of obtaining salvation, led a theological break from the Roman Catholic Church, to start a revolutionary religious path known as the Protestant Reformation (Greenberg et al., 1987; Osborn, 2008; Osborn, 2023). What is not commonly known is the psychological condition Martin Luther suffered from, which arguably led to the theological break from the Roman Catholic Church. However, to deter others from following Martin Luther’s reformed theology, for centuries Catholic polemicists and other religious scholars purported theories of Martin Luther varying from Luther as being controlled by Satan to Luther’s suffering from such mental impairment that his ability to form rational thoughts was non-existent (Osbon, 2008; Osborn, 2023). These alleged theories have been refuted with advancements in psychological and scientific research. In the 1900s, two esteemed clinicians provided a retrospective psychiatric analysis of Luther’s psychological state (Osborn, 2023). One clinician concluded Luther suffered from a degenerative brain disorder while the other clinician, Erik Erikson, concluded Luther suffered from a “borderline psychotic state” (Osborn, 2023, p. 3). These early retrospective psychiatric analyses were refuted by Lutheran experts and greater advancements in psychological and scientific research (Osborn, 2023). With the advancement of the past 50 years in psychopathology, Luther’s mental troubles have undergone a revised psychiatric analysis and can be best classified as what is now known today as OCD, specifically a sub theme known as religious scrupulosity (Osborn, 2023).
Religious Scrupulosity Obsessive-Compulsive Disorder
Scrupulosity is not a new term; it is well known in theological and psychological contexts. The term scruple, originally derived from Latin as scrupulus, held the meaning of a minor jagged pebble stuck in a shoe causing significant distress, discomfort, and negative interference while walking (Weisner & Riffel, 1960). In English, scruple evolved into a term that represented an association with morality and a sensitive conscience (Weisner & Riffel, 1960). Today, after systematically researching OCD dating back as far as the 1800s (Lack, 2023) researchers have identified and operationalized a constellation of clinical psychiatric symptoms known as RS-OCD (Huppert & Siev, 2010; Cefalu, 2010; Leins & Williams, 2018; Moroń et al., 2022) or simply religious scrupulosity (Miller & Hedges et al., 2008; Yorulmaz et al., 2009; Smith-Schrandt, 2023).
RS-OCD is commonly identified in the scientific literature as fearing evil where there is none (Abramowitz & Buchholz, 2020), accepting religious responsibility that is over exaggerated or non-existent (Weisner & Riffel, 1960), the experience of pathological guilt and pathological insistence that a religious or moral standard has been violated (Miller et al., 2024). RS-OCD is a distinctive presentation of OCD and can be difficult to identify as there are significant heterogeneous presentations (Abramowitz & Jacoby, 2014a). Though RS-OCD contains significant heterogeneity, RS-OCD shares a constellation of symptoms, including persistent doubts regarding sin, salvation, obsessive concerns regarding God’s divine punishment and persuasive urges to engage in excessive religious behaviors (Abramowitz et al., 2002). Though sufferers of RS-OCD have the appearance of being highly religious, the obsessions and behaviors are performed out of significant fear of punishment from God, and experienced as anguish, discomfort, and anxiety, resulting in clinical impairment (Miller et al., 2024).
Religious Scrupulosity Development
Theories over the past half century have been purported to explain the etiology and treatment of OCD (Weisner & Riffel, 1960; Rachman et al., 1970; Rachman & de Silva, 1978; Salkovskis et al., 1997; Lack 2023), with some gaining minimal traction and others substantial traction. A leading theory that has gained substantial empirical scientific support is the cognitive-behavioral (CB) model of obsessions (Rachman & de Silva, 1978; Salkovskis et al., 1997; Salkovskis et al., 1998; Rachman, 1997; Rachman, 1998; Abramowitz et al., 2002; Abramowitz & Jacoby, 2014a; Abramowitz & Buchholz, 2020; Lack, 2023). The CB model of obsessions highlights the cognitive and behavioral factors of OCD (Lack, 2023). Indeed, the CB model emphasizes the role of dysfunctional beliefs and misinterpretations of what would otherwise be identified as useless intrusive activity (Abramowitz & Jacob, 2014a). The CB model was in part developed on the work conducted by Beck (1976) and later developed by research conducted by Rachman and de Silva (1976), Rachman (1997), Salkovskis (1985), Salkovskis et al., (1997) and Salkovskis (1999).
Within the CB model, significant emphasis is placed on cognitions, both unwanted ego-dystonic cognitions and ego-syntonic cognitions (Moroń et al., 2022). Regarding religious scrupulosity, instead of deciphering cognitions antagonistic to one’s moral convictions or religious faith as normal unwanted intrusive activity (e.g., Rachman & de Silva, (1978)), cognitions antagonistic to one’s moral convictions or religious faith (e.g., “God is a liar”, “What if I am not saved”, “Did I just lust after her/him”), are interpreted as significantly threatening and worthy of substantial purging or neutralizing efforts (Abramowitz & Jacoby, 2014a).
In line with the CB model (Salkovskis et al., 1997; Salkovskis et al., 1998; Rachman, 1997; Rachman, 1998; Abramowitz et al., 2002; Abramowitz & Jacoby, 2014a; Abramowitz & Buchholz, 2020; Lack, 2023), the misinterpretation of what otherwise would be considered normal unwanted intrusive activity (e.g., Rachman & de Silva, (1978)) causes the individual to engage in religious behaviors (e.g., pray, confess the intrusive thoughts to a pastor or church leader, read scripture, or recite scripture). Though the behaviors have the appearance of pious origins, the behaviors function as neutralizing mechanisms and a negative reinforcement (Mitchell et al., 2020). Further in line with Beck’s (1976) cognitive theory and within the CB model (Lack, 2023), the experience of negative affectivity (e.g., anxiety, panic, disgust) associated with religious laden cognitions or behaviors are subject to misinterpretation and the development of dysfunctional beliefs. Indeed, suffers of religious scrupulosity may experience negative affect in association with a stimulus (e.g., cognition, movie, song, person, place, etc.) and misinterpret the experience of negative affectivity as an indicator from God to perform some religious oriented behavior (e.g., avoid, pray, recite scripture, confess, or seek biblical counsel).
Religious Scrupulosity Development: Can be exacerbated by the Church
Further, as RS-OCD symptomatology involves religious content, obsessions and compulsions are commonly misinterpreted by clinicians and church leadership as high religious devotion (Pirutinsky et al., 2015; Huppert & Siev, 2010). With the outward appearance of religious practices, religious community members, including pastors and church leaders, may ignorantly reinforce obsessive and compulsive rituals by lauding the religious behaviors (Huppert & Siev, 2010; Abramowitz & Bucholz, 2020). Rachman (1997) emphasized, individuals who are taught or learn that cognitions hold significant value will have a greater propensity to obsess, particularly concerning religious teachings and beliefs. Studies highlighted by Abramowitz et al. (2004) indicate strength of religious commitment and religious affiliation are associated with cognitive biases functioning as underlying psychological mechanisms in the etiology and maintenance of OCD. A study conducted by Abramowitz et al. (2002) evidenced results indicating highly religious Protestants demonstrated an increase in fear of God and placed a greater significance on cognitions that were considered sinful when compared to Jewish, Catholic, and less religious Protestants. Further, in a study conducted by Siev and Cohen (2007) a sample described as Christians scored higher on the cognitive bias moral though-action fusion subscale, compared to obsessive samples in normative data. Taken together, though research has not identified that general religious affiliation is a casual link to the development of RS-OCD (Abramowitz et al., 2004), it has illuminated the reconsideration of doctrinal elements, such as, teachings regarding intrusive activity, as religious teachings may be a significant risk factor in the development of OCD (Abramowitz & Bucholz, 2020; Buchholz et al., 2019; Cougle et al., 2013; Cefalu, 2010; Huppert & Siev, 2010; Mauzay & Cuttler, 2018).
Religious Scrupulosity Development: Triple Vulnerability Theory
The idiographic experiences of individual suffering from RS-OCD further align with the specific psychological vulnerability component in the triple vulnerability theory of emotional disorders (Barlow, 2002; Barlow et al., 2014; Sauer-Zavala & Barlow, 2021). Barlow (2002), Barlow et al., (2014) and Sauer-Zavala and Barlow (2021) purport the specific psychological vulnerability as instrumental in the acquisition of specific pathological expressions of anxiety and fear occurring through principles of classical conditioning via observational, direct experiences, or instructional learning (Sauer-Zavala & Barlow, 2021). The specific psychological vulnerability supports the CB model of obsessions (Salkovskis et al., 1997; Salkovskis et al., 1998; Rachman, 1997; Rachman, 1998; Abramowitz et al., 2002; Abramowitz & Jacoby, 2014a; Abramowitz & Buchholz, 2020; Lack, 2023) as the obsessions function as direct experiences and instructional learning which is a critical factor in the acquisition of specific pathological expressions of anxiety and fear. In regard to religious scrupulosity, unwanted intrusive activity (e.g., “Is Jesus real”, “Did I commit a sin”, “Did I pray long enough”) or negative affectivity associated with religious laden content / context, would be considered the specific psychological vulnerability and a critical component in Barlow’s triple vulnerability theory of emotional disorders (Barlow, 2002; Barlow et al., 2014; Sauer-Zavala & Barlow, 2021) that contributes to the development and maintenance of RS-OCD.
Conclusion
Religious scrupulosity though arguably the first recorded instance of what we now know as OCD (Lack, 2023), remains an understudied thematic structure of OCD (Abramowitz et al., 2002; Abramowitz & Jacoby, 2014a). Theories formulated over the past half century (Weisner & Riffel, 1960; Rachman et al., 1970; Rachman & de Silva, 1978; Salkovskis, 1985; Salkovskis et al., 1997; Lack 2023) have illuminated etiological bases for the acquisition of obsessions and compulsive behaviors. The CB model of obsessions (Rachman & de Silva, 1978; Salkovskis, 1985; Salkovskis et al., 1997; Salkovskis et al., 1998; Rachman, 1997; Rachman, 1998; Abramowitz et al., 2002; Abramowitz & Jacoby, 2014a; Abramowitz & Buchholz, 2020; Lack, 2023) provides a cohesive developmental explanation of the etiology and maintenance of religious scrupulosity. Further, the CB model of obsessions (Rachman & de Silva, 1978; Salkovskis, 1985; Salkovskis et al., 1997; Salkovskis et al., 1998; Rachman, 1997; Rachman, 1998; Abramowitz et al., 2002; Abramowitz & Jacoby, 2014a; Abramowitz & Buchholz, 2020; Lack, 2023) aligns with the triple vulnerability theory of emotional disorders purported by Barlow (Barlow 2002; Barlow et al., 2014; Sauer-Zavala & Barlow, 2021).
Though a half century of research has been conducted regarding OCD, there remains significant gaps that are worth additional psychopathological investigation. One area of psychopathological investigation involves the intersectionality between religious teaching, specifically, Pentecostal and Charismatic denominations, and religious scrupulosity. Though research does not suggest religious affiliation as a causal factor in the development of religious scrupulosity (Abramowitz et al., 2004), research does suggest religious doctrine may increase the probability of the development of religious scrupulosity in individuals prone to develop emotional disorders (Abramowitz & Bucholz, 2020; Buchholz et al., 2019; Cougle et al., 2013; Cefalu, 2010; Huppert & Siev, 2010; Mauzay & Cuttler, 2018). Taken together, with further psychopathological investigation into the etiology of religious scrupulosity, perhaps a greater partnership between mental health professionals and religious church leadership can develop with a goal of disseminating psychoeducation regarding the etiology of religious scrupulosity.
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