Scrupulosity: When OCD meets religion
By Hina Javed
23 April 2016
Many people perceive Obsessive Compulsive Disorder (OCD) solely as a condition in which sufferers wash their hands excessively and arrange objects in order and symmetry. While this may not be entirely false, OCD has many sub-categories. One of them involves obsessions that have a religious and moral underpinning. People with this type of OCD fear a sin where there is none.Mental health professionals call religious OCD “scrupulosity,” a distressingly common condition in societies where religiosity is more stringent. Although research is limited, studies suggest that nearly 40 percent of people in the Muslim population are affected by scrupulosity. In this form of OCD, the sufferer’s underlying anxiety is the fear of being responsible for religious and moral failing. Zafar Hasnain, a clinical psychologist and mental health research associate at Interactive Research & Development, says, “Those afflicted with scrupulosity worry that their spiritual values are not good enough and are in direct violation to God.”
A study conducted at the Lady Reading Hospital in Peshawar concluded that culture and religion may influence the manifestation of psychiatric illnesses. Themes of the obsessions noted in this study were predominantly related to religious practices, namely prayers and its associated washings. Compulsions included repetition of prayers, washing, cleaning, and checking rituals.
In many societies, religion is muddled with longstanding traditions that are unverifiable by any empirical standard. These traditions often restrict thinking and are repetitive in nature. When these rituals are increased to a pathological degree, they become obsessions. Mr. Hasnain says, “If you pray or perform a religious rite, you can never really be sure if you did it correctly. Most people will shrug at these doubts and move on with their lives, but faith is never enough for an Obsessive Compulsive as it does not provide them with absolute certainty.”
Blackmailed by OCD in the name of religion
When she was 11, Mariam was admitted to a religious school. She started reading various portions of the Quran, and was obsessed with the Islamic definition of cleanliness. Moreover, she became punctual about her daily prayers and couldn’t escape her obsessive thoughts while performing ablution which involves washing parts of the body a number of times in a fixed order. Any doubt of contamination would lead her to perform the wazoo (ablution) all over again until she did it just right. Mariam’s anxieties took the form of “religious washing,” a term used to define uncertainties relating to the proper execution of wazoo.Likewise, she started doubting the number of rakats (a set of sequential activities) she performed when she offered her prayers. When she bowed down for Sajda, she would question the existence of God and ask herself if she was a Muslim or an atheist. Disrespectful thoughts about God and the Holy Quran would invade her mind randomly and change instantaneously while she prayed. These obsessive thoughts led to rituals, such as kissing the Holy Book repeatedly, performing the ablution and rakats over and over again, to help bring down her anxiety.
“I felt guilty for my demonic thoughts, so to begin with, I first had to get rid of all my sins, ask forgiveness, carry out the punitive rituals, and then I had to pray for protection,” says Mariam, now 24. “Or if something bad happened to me or my family, it would be my fault because I had not shown enough penitence for my satanic thoughts and actions.”
Senior Consultant Psychiatrist Karwan-e-Hayat
Dr Ajmal Kazmi, senior consultant psychiatrist at Karwan-e-Hayat, explains the “thought-action fusion” behavior. “Sufferers assume that just having a mere thought means that it requires special attention,” he says. “They believe that having a bad thought is as sinful as committing the act.” He further illustrates that in OCD, obsessions are recurrent and persistent thoughts that enter a person’s mind despite their effort to exclude them whereas compulsions are purposeful behaviors performed in a stereotyped way. A compulsion is usually followed by an obsession as if it plays the function of reducing the distress caused by the latter. In Mariam’s case, the compulsion of kissing the Holy Book often followed her obsessional thoughts of having disrespected God and the Holy Quran.Mariam had been steadfast in her devotion since an early age. But, when her obsessions took a toll on her schoolwork and daily life, she’d try to avoid anything and anyone that triggered her spiritual obsessions. Conflicting worries consumed her mind and she was becoming depressed. Fortunately, Mariam received psychological intervention which alleviated her suffering and helped her regain control of her life.
Mariam’s example of scrupulosity is one of the many variations a sufferer may have with this type of OCD. Sadia Mazhar, a clinical psychologist at Karwan-e-Hayat, says, “individuals with scrupulosity aren’t necessarily religious but feel hyper responsible to their moral ideals.” She further adds that religious individuals usually experience doubts, guilt, and even some anxiety due to which they need constant reassurance from others and themselves.
What causes scrupulosity?
While rituals and traditions vary across religions, belief systems do not cause OCD. “It is known to be genetic and tends to run in families,” says Mr Hasnain. “It may be more evident in conservative cultures than in the less conservative ones, but even in that case, religion does not cause the OCD.” He explains that OCD has an extraordinary ability to target sufferers, attacking them where they are the most vulnerable. People who are biologically predisposed to OCD will be triggered at some event or experience in their lives and develop full-blown OCD.Treatment: a delayed response
Regrettably, misinformation and lack of awareness may delay the treatment for scrupulosity. According to Dr Kazmi, it can take around 14 to 15 years for individuals suffering from religious OCD to seek the right treatment. To some degree, OCD sufferers create their own rituals to decrease their level of guilt and anxiety. What they do not realize is that the incessant need for reassurance is symptoms of OCD. “Cognitive-behavioral therapy that also includes Exposure and Response Prevention is highly effective in beating back OCD, including scrupulosity,” says Ms. Mazhar. She explains that people with scrupulous obsessions crave certainty that isn’t possible. They want guarantee that awful things won’t happen to them.Ms. Mazhar uses two primary methods of treatment. One is Cognitive Therapy, which defies erroneous thinking common to OCD sufferers. The other is a behavioral treatment known as Exposure and Response Prevention (ERP).
Cognitive Behavioral Therapy (CBT)
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She explains some of the cognitive distortions people with scrupulosity have. They fear negative religious consequences arising from the inability to control intrusive thoughts and think in black and white. There are no gray areas. There is nothing in between. Moreover, they find it hard to control their thoughts and usually find that the thoughts become harder to prevent. They become intolerant to uncertainty and want immediate reassurance, and think that if they don’t practice their faith perfectly, they have failed.
“In CBT, patients learn to correct their thinking errors by challenging them. Behavior therapy is also used as a way to get over their fears in a different way,” says Ms. Mazhar.
Exposure and Response Prevention (ERP)
With ERP, patients are exposed to their irrational, anxiety-provoking thoughts, while refusing to use rituals to diminish their anxieties. “They learn to tolerate their obsessions instead of avoiding them, which takes away the power of their thoughts,” says Ms. Mazhar. She goes on to explain that when the mind and body are habituated to the distressing thoughts, the patients learn to label those obsessions as OCD and let them go instead of chasing those thoughts away with compulsions. This way the thoughts become less bothersome.Ms. Mazhar points out that while in therapy, patients are given assignments that instigate their provocative thoughts. Then comes the response prevention in which sufferers are advised not to indulge in any compulsions or safety behaviors to quell their anxieties, such as repeating reassuring phrases. This way, they habituate their anguishing thoughts and the OCD thoughts soon lose their power.
Other treatment options
Sometimes CBT is not enough to treat severe cases of OCD. In such instances, seeking medical treatment becomes necessary. Dr Kazmi says, “Medical professionals usually prescribe antidepressants to treat OCD. These medicines control imbalances in serotonin levels arising due to OCD.”Serotonin is a chemical that is produced by the brain and used as a messenger. “If your brain does not have enough serotonin, then the entire communication might get botched up,” he says. “These medications that are called Selective Serotonin Reuptake Inhibitors (SSRIs) inhibit the production of serotonin. Adding these to the body can help boost the serotonin level and get the brain back on track.”
