The Relationship Between Religiosity, Moral Thought-Action Fusion, and Scrupulosity: A Discussion

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Abstract

The discussion herein pertains to obsessive-compulsive disorder (OCD), specifically concerning a unique presentation known as scrupulosity, which involves pathological concerns over moral and religious issues. Features and characteristics of OCD are briefly discussed, specifically, obsessions and compulsions, and how these symptoms manifest in the presentation of scrupulosity. The discussion further examines the existing gap in the literature, which encompasses deficiencies in both clinical psychology and the emerging discipline of moral psychiatry. Additional features of scrupulosity are discussed, namely, poor insight, given that scrupulosity symptoms overlap with issues of morality, religious teachings, and religious practices. A discussion was included on how religious authority figures might inadvertently contribute to the development of scrupulosity, which has clinical implications, specifically in providing psychoeducation for them regarding scrupulosity. A review of the extant literature was conducted. The review includes both conceptual and empirical literature on the specific constructs of interest: religiosity, scrupulosity, and thought-action fusion (TAF). Lastly, future research directions were outlined, emphasizing the need to address existing gaps in the literature regarding specific Christian orientations, Pentecostalism, and Charismatic-oriented religious teaching.

Keywords: obsessive-compulsive disorder, moral thought-action fusion, religiosity, scrupulosity

The Relationship Between Religiosity, Moral Thought-Action Fusion, and Scrupulosity

Obsessive-Compulsive Disorder (OCD) is a disabling psychiatric condition that affects between 1.10% and 1.80% of the global population according to some reports (American Psychiatric Association, 2022), while other sources indicate prevalence rates of up to 4% (Coughtrey & Melli, 2026). It is characterized by symptoms that are described as persistent intrusive cognitive activity or compulsive behaviors performed in response to the intrusive cognitive activity (American Psychiatric Association, 2022). These symptoms become demanding and incapacitating, causing clinically significant impairment or distress in a life domain such as social, occupational, or other important areas of functioning (American Psychiatric Association, 2022).

Within the literature, OCD is regarded as a highly heterogeneous psychological condition (Abramowitz & Hellberg, 2020; Hellberg et al., 2020). Indeed, while obsessions and compulsions constitute the fundamental features of OCD, the particular content of obsessions and compulsions may vary considerably (Abramowitz & Hellberg, 2020) and can evolve throughout the lifespan of an individual with OCD (Hellberg et al., 2020). Provided the heterogeneous nature of OCD (Abramowitz & Hellberg, 2020; Hellberg et al., 2020), several gaps in the literature exist.

A presentation of OCD that has limited representation in the scientific literature is scrupulosity (Raj et al., 2024). This gap in the OCD literature is further shared in the literature regarding morality. Indeed, as delineated by Summers and Sinnott-Armstrong (2019), moral psychiatry, examining moral issues through the lens of psychological disorders, constitutes an underexplored area within the domain of morality. As Summers and Sinnott-Armstrong (2019) note, expanding the scope of moral psychiatry will significantly advance the broader discipline of morality. They propose that psychiatric conditions involving moral issues can shed light on morality, given that moral philosophy often involves abstract and idealized work (Summer & Sinnott-Armstrong, 2019). A psychiatric condition they identified as an excellent candidate for the expansion of the moral psychiatry literature is scrupulosity (Summer & Sinnott-Armstrong, 2019).

Further, implied in the conceptual literature (Abramowitz & Jacoby, 2014), and demonstrated in the empirical literature (Williams et al., 2013; Bailey et al., 2023), several constructs and underlying cognitive mechanisms are associated with scrupulosity and OCD. These include religiosity (Williams et al., 2013; Bailey et al., 2023) and thought-action fusion (TAF; Williams et al., 2013). Thus, the discussion herein proposes that higher levels of religiosity are positively correlated with greater moral TAF, as specific religious doctrines underscore that cognitive activity is morally equivalent to action and reinforce the importance of monitoring and regulating internal mental states. Taken together, further exploration of scrupulosity will undoubtedly address gaps in both the OCD and morality literatures and provide greater insight into its phenomenology.

Scrupulosity, Insight, and Religious Authorities

 Scrupulosity, recognized as a manifestation of OCD (Pirutinsky et al., 2015; Johnson et al., 2024), encompasses persistent and distressing intrusive cognitive and internal activity pertaining to moral or religious issues, accompanied by compulsive behaviors enacted in response to the intrusive cognitive activity and internal experiences (Witzig et al., 2013; Buchholz et al., 2019; Johnson et al., 2024; Siev et al., 2025). Furthermore, the symptomatology of scrupulosity has been delineated into four presentations based on clinical observations (Abramowitz & Jacoby, 2014) and reviewed by Moroń et al. (2022). These encompass ego-dystonic thoughts that are experienced as intrusive, involving content related to immoral acts, sexuality, and violence, which are partially appraised within a religious framework. Additionally, they include ego-dystonic thoughts specific to religion, such as images of religious figures that may be regarded as blasphemous, often accompanied by behaviors aimed at neutralization, whether or not they are religiously themed (Abramowitz & Jacoby, 2014; Moroń et al., 2022). Furthermore, they consist of ego-syntonic thoughts concerning one’s faith, including doubts that can escalate into obsessive concerns, thereby prompting excessive reassurance-seeking from religious authorities or engagement in religious practices to reaffirm faith. This also includes obsessive preoccupations with whether moral rules or religious commandments have been followed sufficiently (Abramowitz & Jacoby, 2014; Moroń et al., 2022).

In addition to the aforementioned symptomatology of scrupulosity, another noteworthy aspect is that the content of its symptoms is often unrecognized and misinterpreted as indicating issues with morality or faith (Shapiro, 2023). Indeed, an empirical investigation conducted by Tolin et al. (2001) indicated that patients with religious obsessions may be more prone than others to exhibit limited insight into their symptoms. Poor insight into scrupulosity symptoms and other manifestations of OCD were further examined empirically by Siev et al. (2021). The results indicated that, across various OCD presentations (e.g., contamination), there were no statistically significant differences concerning clinical measures, including insight. However, when focusing exclusively on scrupulosity, significant distinctions became apparent. Specifically, a noteworthy difference was observed in the within-group patterns (Siev et al., 2021). Among individuals with scrupulosity, a stronger correlation was observed between reduced insight and symptom severity (Siev et al., 2021). In other words, the association between poor insight and symptom severity was statistically significant solely within the scrupulosity subgroup (Siev et al., 2021).

Furthermore, existing literature has examined how religious leaders might unintentionally promote or laud engagement with symptoms of scrupulosity, thereby reinforcing such behaviors. Abramowitz and Jacoby (2014) discuss that it can be challenging to distinguish normative religious or moral practices from symptoms of scrupulosity. Consequently, religious clergy, leaders, and teachers may, perhaps inadvertently, endorse and commend engagement in what seem to be normative religious practices but are, in fact, symptoms of scrupulosity (Abramowitz & Jacoby, 2014). Huppert and Siev (2010), in their discussion regarding clergy involvement in the treatment of scrupulosity, caution that clergy members may inadvertently provide detrimental guidance to individuals suffering from scrupulosity. Such guidance may encompass the suggestion that the presence of evil thoughts will condemn a person to hell and that these thoughts must be abolished (Huppert & Siev, 2010). Additionally, they may imply that increased religious activity or practice (e.g., praying more, reading the bible more often, quoting bible passages) will diminish the frequency of intrusive thoughts, and that it is appropriate for the scrupulosity sufferer to engage in overt avoidance of behaviors perceived as sinful or immoral (Huppert & Siev, 2010). Pirutinsky et al. (2015) further discuss this notion, stating that symptoms of scrupulosity masquerade as religion, making it difficult for clinicians to distinguish scrupulosity symptoms from normative religious practices. Raj et al. (2024) suggest that religious authorities should become aware of the disorder, as awareness will help them avoid making statements that may provoke moral conflict and perhaps help those suffering from scrupulosity gain a greater moral understanding of the disorder. Having a more comprehensive understanding by sufferers of scrupulosity and religious authorities, along with increased insight into the symptomatology of scrupulosity, is advantageous, as the existing empirical literature has implicated two prominent constructs associated with scrupulosity: religiosity (Abramowitz et al., 2002; Raj et al., 2024) and moral thought-action fusion (Moral-TAF; Siev et al., 2017).

Thought-Action Fusion, Religiosity, and Scrupulosity

Thought-Action Fusion

A psychological mechanism identified as a risk factor for OCD, and consequently for scrupulosity, is TAF (Siev et al., 2017). TAF was first elucidated by Rachman (1993), who described the psychological fusion between thought and action in his work on obsessions, responsibility, and guilt. Indeed, Rachman (1993) argued that individuals who encounter unwanted intrusive phenomena and ascribe disproportionate significance to them may encounter what he characterizes as an “exaggerated sense of responsibility” (p. 31). He further notes that the undue significance one attaches to intrusive phenomena can lead to a psychological fusion between thought and action (Rachman, 1993). This psychological fusion constitutes a dysfunctional belief in which the experience of an obsessional unwanted thought is regarded as morally equivalent to fulfilling the action (Rachman, 1993). Rachman (1993) explains that the psychological fusion between thought and action leads the individual to perceive it as immoral to have a thought that may be deemed blasphemous or reprehensible and to believe that the person bears moral responsibility for such a thought.

The phenomenon of psychological fusion between thought and action was empirically verified in a seminal study by Shafran et al. (1996). The study by Shafran et al. (1996) was an extension of a previous empirical investigation into the responsibility appraisal of unwanted intrusive activity, conducted by Rachman et al. (1995). In the empirical study conducted by Shafran et al. (1996), a two-factor solution was identified concerning what is now known as TAF, formerly referred to as psychological fusion (Rachman, 1993). These two factors include -likelihood-TAF and Moral-TAF (Sharfran et al., 1996).

Since the emergence of TAF, several empirical investigations have explored its role as a psychological mechanism associated with religiosity, scrupulosity, and OCD (Rassin & Koster, 2003; Siev & Cohen, 2007; Siev et al., 2010; Berman et al., 2010; Cougle et al., 2013; Williams et al., 2013; Inozu et al., 2014; Siev et al., 2017; Siev et al., 2025). In the empirical analysis carried out by Williams et al. (2013), multiple assessments were performed. One analysis incorporated a one-tailed Pearson correlation for each religious group with various psychological constructs; the constructs relevant to this discussion were religiosity, OCD symptoms, and Moral-TAF (Williams et al., 2013). Concerning religiosity and Moral-TAF, a significant correlation was observed solely within the Christian group (Williams et al., 2013). In addition, a finding regarding religious devotion and Moral-TAF levels was noteworthy. Indeed, Williams et al. (2013) found no statistical differences in religious devotion between Jewish and Christian participants, indicating similar levels of devotion; nevertheless, the noteworthy finding was that the Christian cohort demonstrated statistically significant higher levels of Moral-TAF than the Jewish cohort. Furthermore, a moderated mediation analysis indicated a significant conditional indirect effect only among Christian participants (Williams et al., 2013). In other words, for the Christian cohort, only religiosity increased levels of TAF, which in turn led to a higher level of OCD related symptoms (Williams et al., 2013).

Concerning TAF’s function as a mechanistic pathway linking religiosity and OCD symptoms, Inozu et al. (2014) reported analogous findings, among individuals identifying Islam as their religious affiliation. Indeed, Inozu et al. (2014) investigated the indirect effect of religiosity on OCD symptoms through one of their proposed mediators, TAF. Their mediation analysis demonstrated a significant indirect effect, indicating that religiosity had an indirect effect on OCD symptoms that was mediated through TAF. In addition, although not a mediation analysis, Siev et al. (2017) identified significant correlations between religiosity and Moral-TAF. Siev et al. (2017) found that across the entire sample, which included Muslim and Jewish participants, religiosity significantly correlated with Moral-TAF. The results further identified a statistically significant correlation between Moral-TAF and scrupulosity (Siev et al., 2017). Taken together, these findings demonstrate that religiosity, Moral-TAF, and OCD symptoms are directly and indirectly related, regardless of religious orientation.

Religiosity

Throughout the empirical literature, numerous studies have examined the influence of religiosity on scrupulosity and OCD (Abramowitz et al., 2002; Nelson et al., 2006; Yorulmaz et al., 2009; Siev et al., 2010; Cougle et al., 2012; Mauzay et al., 2016; Bailey et al., 2023). Indeed, the empirical investigation by Yorulmaz et al. (2009), which examined the role of religiosity in OCD symptoms, found that religiosity had a main effect on various types of metacognitions, specifically on the importance and control of thoughts, as well as on the use of worry as a thought-control strategy. Furthermore, the results indicated that, compared with low-religious participants, highly religious participants, regardless of religion, emphasized the importance of controlling their thoughts and endorsed greater Moral-TAF (Yorulmaz et al., 2009). Among Christian participants, there was a meaningful difference between high and low religiosity on Moral-TAF: high-religiosity Christian participants scored significantly higher than low-religiosity Christian participants (Yorulmaz et al., 2009). There were no significant differences between high Christian participants and high Muslim or Low Muslim participants regarding Moral-TAF (Yorulmaz et al., 2009). Regarding correlational analysis, the only OCD-related symptoms and cognitions that showed significant correlations were Moral-TAF and the belief in the significance of controlling thoughts, which were significantly correlated among Christian participants (Yorulmaz et al., 2009). The Muslim participants only demonstrated a positive correlation with Moral-TAF (Yorulmaz et al., 2009).

The findings by Yorulmaz et al. (2009) align with previous empirical research conducted by Abramowitz et al. (2004) and Cohen and Rozin (2001). Indeed, concerning the findings regarding religiosity and OCD metacognitions, Abramowitz et al. (2004) identified that highly religious Protestants exhibited significantly elevated levels of OCD-related metacognitions compared to an atheistic group. Furthermore, a moderate group of Protestant Christians demonstrated significantly lower levels of the importance of thoughts subscale than the highly religious Protestant cohort (Abramowitz et al., 2004). In addition, results indicated that the highly religious Protestant cohort demonstrated more severe obsessional symptoms when compared to both the moderate Protestant cohort and the atheist cohort (Abramowitz et al., 2004). These findings regarding Protestant metacognitive beliefs aligned with Cohen and Rozin (2001), who found that Protestant participants scored higher on the importance-of-thought scale than Jewish participants and differed significantly in their views on the immorality of thoughts; in other words, Protestant participants rated cognitions as more immoral than Jewish participants.

In a more recent empirical analysis of the role of religion in scrupulosity, Bailey et al. (2023) reported findings that corroborated those of previously reviewed studies. Indeed, results indicated that those who identified as religious were more likely to endorse symptoms of scrupulosity (Bailey et al., 2023). Furthermore, a mediational analysis was conducted by Bailey et al. (2023) regarding religiosity, scrupulosity, and mental health impairment. The results identified that the relationship between religiosity and mental health impairment was explained by religious scrupulosity (Bailey et al., 2023).

It is important to acknowledge that, although the aforementioned empirical studies have identified a role for religiosity in OCD metacognitions and OCD severity, several studies have not found a contributory role of religiosity. Indeed, the findings from Nelson et al. (2006) depict a distinctly different perspective. The findings of Nelson et al. (2006) indicate that although Protestant Christians achieved statistically significantly higher scrupulosity scores than the non-religious cohort, these scores did not correlate significantly with measures of religious devotional strength. These findings were corroborated in the empirical analysis conducted by Witzig and Pollard (2013). In their study, Witzig and Pollard (2013) sought to explore several correlations between obsessional beliefs and religious fundamentalism. The results pertinent to religiosity and OCD metacognitions were similar to those of Nelson et al. (2006). Indeed, their results demonstrated a non-significant relationship between scrupulosity scores and religious devotional strength. Taken together, the evidence of mixed results regarding the role of religiosity in scrupulosity suggests that further empirical analysis is warranted.

Future Research and Implications

            As previously discussed, there are several gaps in the existing body of literature on OCD and morality. Regarding gaps in the morality literature, Summers and Sinnott-Armstrong (2019) propose that the field would benefit greatly from developing what they describe as moral psychiatry: the investigation of moral issues through a psychological lens. They assert that this approach will improve the overall moral literature and suggest scrupulosity as a potential candidate for such an expansion, given that a characteristic of scrupulosity is experiencing excessive guilt, anxiety, distress, and an exaggerated sense of responsibility regarding moral issues (Summers & Sinnott-Armstrong, 2019).

The proposition to use scrupulosity as a candidate for developing the moral psychiatry literature aligns with the clinical psychology literature, as scrupulosity has been identified as an underexplored presentation of OCD (Raj et al., 2024). Furthermore, given the heterogeneity of scrupulosity, TAF, a cognitive mechanism related to OCD as identified in empirical literature (Williams et al., 2013), has yet to be explored across several religious denominations. This matter is significant, given that cultural and religious differences may lead to varying emphases in religious doctrines or cultural practices on the importance and control of thoughts, and may also elucidate the relationship between TAF and religious teachings (Cohen & Rozin, 2001; Abramowitz et al., 2002; Rassin & Koster, 2003; Abramowitz et al., 2004; Yorulmaz et al., 2009; Siev et al., 2010; Cougle et al., 2012; Williams et al., 2013; Inozu et al., 2014; Mauzay et al., 2016; Siev et al., 2017; Bailey et al., 2023; Siev et al., 2025).

Furthermore, Pentecostalism and Charismatic Christianity are particular Christian orientations that, to the best of my knowledge, have not undergone empirical investigation concerning religiosity, scrupulosity, and Moral-TAF. Qualitative phenomenological analysis has demonstrated that Pentecostal-oriented Christians place significant emphasis on appraising internal bodily and cognitive experiences, which are informed and interpreted through a leader-regulated interpretive framework (Inbody, 2015). In an additional qualitative phenomenological study, several Charismatic-oriented church members believed that God was placing thoughts or communicating with them through their cognitions and emotions (Dein et al., 2015). Many of the participants in the study described their thoughts as ‘God’s voice’ entering their minds, described the experience of emotions as God communicating with them, and saw learning to discriminate between ‘God’s voice’ and their own thoughts as an important learning process (Dein et al., 2015). Though not explicitly discussed in either qualitative study, these studies suggest a significant theological doctrine and religious practice that relate to both Pentecostal- and Charismatic-oriented Christians: the importance of cognitions and learning to appraise cognitions and emotions in order to better understand ‘God’s voice’. This doctoral teaching and religious practice have been circulated within Christian communities by prominent pastors, especially those affiliated with Pentecostal and Charismatic movements (Dollar, 2008; Winston, 2008). Investigating these beliefs has significant scientific and clinical implications, as the scientific literature indicates that such theological doctrines and practices can foster maladaptive metacognitive beliefs, such as TAF and the importance and control of thoughts (Abramowitz & Jacoby, 2014; Abramowitz et al., 2020; Albińska, 2022). Taken together, expanding the scientific literature on scrupulosity, Moral-TAF, and religiosity among Pentecostal and Charismatic Christians will address the previously mentioned gaps. This expansion may offer valuable insights for religious leaders on scrupulosity and improve clinicians’ understanding of the mechanistic pathways underlying this condition.

Conclusion

OCD is a debilitating psychiatric disorder that affects millions around the world (American Psychiatric Association, 2022). Part of the complexity of OCD lies in the significant heterogeneity in presentation (Abramowitz & Hellberg, 2020; Ayoub et al., 2024). A presentation of OCD that has been understudied in the literature from a clinical psychological perspective and morality perspective is scrupulosity (Summers & Sinnott-Armstrong, 2019; Raj et al., 2024).

As previously discussed, scrupulosity involves an excessive preoccupation with obsessions and compulsive behaviors related to moral or religious concerns (Abramowitz & Hellberg, 2020; Sharma et al., 2025). Given these excessive obsessional concerns, religiosity, TAF, and symptoms of OCD have been an interest within empirical literature. Indeed, as discussed herein, numerous research studies have established an empirical correlation between religiosity, scrupulosity, and dysfunctional metacognitive beliefs, particularly TAF (Cohen & Rozin, 2001; Abramowitz et al., 2002; Rassin & Koster, 2003; Abramowitz et al., 2004; Yorulmaz et al., 2009; Siev et al., 2010; Cougle et al., 2012; Williams et al., 2013; Inozu et al., 2014; Mauzay et al., 2016; Siev et al., 2017; Bailey et al., 2023; Siev et al., 2025). However, as discussed previously, although empirical research has demonstrated a significant association between these variables, other studies have found no association or only a nonsignificant one (Nelson et al., 2006; Witzig & Pollard, 2013).

In addition, empirical research reviewed has further demonstrated that particular religions significantly contribute to an increase in dysfunctional cognitive beliefs that, in turn, significantly increase OCD related symptoms (Williams et al., 2013). The literature further supports this line of reasoning that religious teaching may influence the misappraisal of internal experiences, namely, cognitions (Nelson et al., 2006; Greenberg & Huppert, 2010; Inozu et al., 2012; Abramowitz & Jacoby, 2014; Siev et al., 2017; Abramowitz & Buchholz et al., 2020; Albińska, 2022). Further, as discussed, qualitative phenomenological studies (Inbody, 2015; Dein et al., 2015) have found that Pentecostal- and Charismatic-oriented Christians place significant emphasis on their internal cognitive, emotional, and physiological experiences. Consequently, the religious teachings and practices demonstrated by Inbody (2015) and Dein et al. (2015) could be the very ones that increase dysfunctional metacognitive beliefs, such as TAF, and others.

Taken together, given the mixed findings (Nelson et al., 2006; Bailey et al., 2023), gaps within the existing literature (Summers & Sinnott-Armstrong, 2019; Raj et al., 2024), and the conceptual and empirical implications of religious teachings influencing the increase in dysfunctional metacognitive beliefs (Williams et al., 2013; Abramowitz & Buchholz et al., 2020), it is advisable to pursue further research. Additionally, a more comprehensive examination of scrupulosity could offer significant clinical and religious advantages. Indeed, expanding the understanding of scrupulosity may yield novel clinical insights that could assist both mental health professionals and clergy members within their respective religious communities.