Abstract
Importance:
Religiosity and guilt are commonly featured in obsessive-compulsive disorders (OCD). The role of religiosity and guilt in OCD has been frequently studied in the literature and suggested that greater religiosity/spirituality, paranormal beliefs, and magical ideation have often been associated with enhanced obsessive-compulsive behavior. India being a multi-religious country, it is particularly notable that a research was required to assess the role of religiosity and guilt in symptomatology and outcome in OCD, a condition in which religious themes are often present. It has also been documented that the fear of guilt for doing something irresponsibly may lead to OCD symptoms.
Objective:
The study aimed to seek the role of religiosity and guilt in symptomatology and outcome of OCD. This study also aimed to assess the pattern of symptomatology of patients with OCD and the relation between religiosity and guilt.
Settings and Design:
This was a single-centered, prospective study for one year with six months follow-up.
Methods and Material:
Fifty OCD subjects of either gender, aged between 18 years and 45 years were included in this study and were assessed using Yale-Brown Obsessive Compulsive Scale, Belief into Action Scale, and The Guilt Inventory instruments for the measurement of OCD severity, religiosity, and guilt, respectively. All the recorded data were analyzed using IBM® SPSS® version 20.1.
Results:
At baseline, OCD severity was positively correlated with religiosity and guilt, while after 6-month follow-up, OCD severity was negatively correlated with religiosity and positively correlated with guilt.
Conclusion:
Religiosity and guilt have significant effect on the symptomatology and outcome of OCD.
Keywords: obsessive-compulsive disorder, religiosity, guilt
Texts: Introduction
Obsessive-compulsive disorder (OCD) is a mental disorder characterized by excessive or unreasonable obsessions or compulsions, which cause prominent distress in the individual experiencing them. Obsessions are the eruptions of uncontrollable intrusive thoughts, impulses, or images that an individual recognizes as internally generated, which are not just excessive perturbations about real-life problems that an individual tries to ignore or neutralize. Whereas, compulsions are mental acts or repetitive behavior, which are attempts to either prevent or reduce distress as a response to an obsession, but that are clearly excessive and usually not really connected to the event they should prevent.1 The most common obsessive symptoms include contamination, pathological doubt, need for order or symmetry, aggression, somatic dysfunctions, and sexual obsessions. Whereas, the most common compulsive symptoms are checking, washing, counting, hoarding, and precision. In OCD patients, meaningless and repetitive behaviors (e.g., washing, counting, etc.) counteract the anxiety caused by obsessive thoughts (e.g., contamination, symmetry, and exactness preoccupations). For example, fears of illness and contamination lead to cleaning and washing. Some of these symptoms get stable over sometime.2 OCD is a psychiatric affliction with a lifetime prevalence of 2.3 to 3.8% in the general population.3 The literature study also suggested that greater religiosity/spirituality, paranormal beliefs, and magical ideation have often been associated with enhanced obsessive-compulsive behavior.4 It has also been documented that the fear of guilt for doing something irresponsibly may also lead to OCD symptoms.5
The relationship between religiosity, guilt, and OCD has been a matter of concern for a long time. Religious OCD symptoms include pathological doubt, religious themes, hyper-morality, worry about sin, and excessive religious behavior, which are often referred to as scrupulosity in psychological literature.6,7
Strong religiosity may be considered as a potential risk factor for OCD.5–11 It was also reported that greater religiosity was associated with greater guilt in OCD patients.11 For example, several studies demonstrated positive relationships between religiosity and maladaptive beliefs relevant to OCD, including perfectionism, overvalued responsibility, and importance and control of thoughts.12–16 Additionally, some studies also demonstrated that the effect of religiosity on OCD-related cognitions might differ among various religions or even different religious denominations due to differences in religious doctrines and teachings. Furthermore, in many normal religious believers, guilt about sinning can be alleviated through the ritual of religious confession. Not surprisingly, those with religious obsessions and rituals, often feel a compelling need to follow religious rituals, such as prayer, confession, and church attendance, perfectly.17 For instance, a study suggested that highly religious individuals tend to have greater obsessions related to their increased sense of personal guilt and beliefs that they are responsible for controlling unwanted, threatening intrusive thoughts.18
However, it is obligatory to understand that link between enhanced religiosity, guilt, and certain obsessions and compulsions do not necessarily specify that being highly religious leads to the development of certain OCD symptoms or increased overall OCD symptomatology. Many individuals with OCD may become more religious in response to their OCD symptoms. Because religious themes are often salient in OCD, it is possible that the development of this disorder in some individuals are influenced by religious factors. As OCD receives increasing attention due to its high prevalence, biological bases, and responsiveness to pharmacologic and behavioral treatments, further research is needed to explore the psychosocial variables that may influence its development and affect treatment outcome.
So, the present study aimed to examine the role of religiosity and guilt in symptomatology and outcome in OCD and also to assess the pattern of symptomatology in OCD.
Design & Setting
This was a single-center and prospective study conducted on the consecutive patients registering as out-patient or in-patients from the department of psychiatry of a tertiary care hospital setting in India. The study was approved by the institutional ethical committee and written informed consent was obtained from each study subject before the recruitment in the study.
Participants
Patients of either gender, aged between 18 years and 45 years, and diagnosed with OCD according to the ICD-10 using DCR criteria were included in this study. While, patients who had OCD associated with any other co-morbid psychiatric illness, head injury, recent cerebrovascular accident or any other organic illnesses, mental retardation, co-morbid substance abuse, and severe medical ailment like neurological, respiratory, cardiac, hepatic, renal, and other medical illnesses that may interfere with the evaluation and outcome of subjects under the study were excluded.
Main outcome & Measures Instruments
Sociodemographic Profile Sheet
The sociodemographic profile sheet/interview Performa was administered to the study subjects to record demographic variables including age, sex, education, occupation, religion, marital status, duration and course of illness, and type of family.
Yale-Brown Obsessive-Compulsive Scale (YBOCS)
The YBOCS is a clinician-administered 19–46 item semi-structured scale designed to rate the severity and type of symptoms using a symptom checklist in patients with OCD. Rating is on a 5-point Likert scale, but only items 1–10 (excluding items 1b and 6b) are used to determine the total score. Taking about 60–90 minutes to administer, the total Y-BOCS scores range from 0 to 40, with higher scores indicating greater severity. A total Y-BOCS score of below 7 denotes a subclinical case, 8–15 denotes mild, 16–23 denotes moderate, 24–31 denotes severe, and 32–40 denotes extreme cases of OCD.
Belief into Action Scale (BIAS)
Religiosity was measured using the BIAS scale. The BIAS scale consists of 10 items. Nine of the 10 items are rated on a Likert type scale from 1–10; one item (#1) is scored 10 if the respondent indicates-relationship with God as his or her highest priority in life, whereas all other responses received a score of 1. The total score ranges from 10 to 100, with higher scores indicating greater religiosity.
The Guilt Inventory (TGI)
The Guilt Inventory made up of Trait Guilt Scale consists of 20 items, the State Guilt Scale has 10 items, and the Moral Standards Scale has 15 items. The item responses are rendered on a 5-point Likert scale with verbal anchors (e.g., strongly agree [5], agree [4], etc.). For each scale, approximately half the items are worded in the reverse direction to reflect lesser guilt or lower standards. The scales are administered as one 45-item inventory with items scored for each scale randomized throughout.
Procedure
The patients who met all the inclusion and exclusion criteria of the study were recruited. After enrollment, the patients were evaluated for using above mentioned psychometric scales and followed up for a period of 6-months at an interval of once every month. At every follow-up visit, the YBOCS scale was applied and then final scores at the end of the study were recorded. Patients were asked to continue their treatment as prescribed by their consultant. Concomitant medications used by the patients were also recorded. The collected data were subjected to appropriate statistical analysis and was kept confidential.
Statistical Analysis
The data about clinical details were entered in the form of a data matrix in Microsoft® Excel® and analyzed using IBM® SPSS® version 20.1. Descriptive statistics for categorical variables were represented in the form of frequencies and percentages; and means and standard deviations for continuous variables. The association between various parameters and variables was explored using Pearson’s Chi-Square test and p-value <0.05 was considered significant. The other parametric tests used were one-way analysis of variance test (ANOVA), Student t-test, and Pearson correlation.
Results
Out of 75 screened OCD patients, 50 were included and 25 were excluded. The reason for exclusion was: patients did not come for follow up (15 patients), refused to give consent (5 patients), and did not meet the inclusion and exclusion criteria (5 patients).
Sociodemographic Profile
As described in Table 1, the majority of the patients (54%) were in the age group between 21–30 years, while a low proportion of the patients (40%) were in the age group between 31–40 years. The difference between the age of the patients was not significant (p-value = 0.882). A majority of the patients were males (54%) and the difference between males and females was not significant (p-value = 0.801). A high and similar proportion of the patients were graduates (34%) and passed high school education (40%). The difference between the educations of the patients was not significant (p-value = 0.882). A majority of the patients belonged to the Sikh religion (70%) followed by the Hindu religion (28%) and only 1 patient was from the other religion. The difference between the religion of the patients was not significant (p-value = 0.198). A similar proportion of the patients were from rural and urban areas (50% in each category). The monthly income of the majority of the patient’s family was ⩽6323 (54%) and the difference between the income of the patients was highly significant (p-value = 0.007). The occupation of the most of patients (⩾15% of the total) was the plant and machine operators and assemblers (34%), and craft and related trade workers (24%). The difference between the occupation of the patients was highly significant (p-value = <0.001). Most of the patients were from the Nuclear family (54%) followed by the Joint family (46%) and the difference between the both was not significant (p-value = 0.81). Most of the patients were married (52%) and the difference between the marital status of the patients was highly significant (p-value = 0.027). The lifestyle of the high and similar proportion of the patients was sedentary (43.3%) and moderate (40%). Only a few patients (5 patients) were performing high work. The duration of the illness for most of the patients (⩾10%) was 1–12 months (40%), 13–36 months (26%), 37–72% (16%), and 73–120 (10%) months. The difference between the duration of illness was significant (p-value = 0.002; Table 1).
Table 1. Distribution of Sample According to Sociodemographic Profile Variables.
| Variables | Categories | No. of Subjects (%) |
Chi-square value (X2) |
df | p* Value | |||||
| Age | ⩽20 | 0 (0) | 2.368 | 1 | 0.882 (NS) |
|||||
| 21–30 | 27 (54) | |||||||||
| 31–40 | 20 (40) | |||||||||
| 41–50 | 3 (6) | |||||||||
| >50 | 0 (0) | |||||||||
| Gender | Male | 27 (54) | 2.368 | 1 | 0.801 | |||||
| Female | 23 (46) | |||||||||
| Transgender | 0 (0) | |||||||||
| Education | Illiterate | 0 (0) | 2.368 | 1 | 0.8820 (NS) |
|||||
| Primary | 4 (8) | |||||||||
| Middle | 5 (10) | |||||||||
| High school | 20 (40) | |||||||||
| Higher secondary | 3 (6) | |||||||||
| Graduate | 17 (34) | |||||||||
| Postgraduate | 1 (2) | |||||||||
| Total | 50 (100) | |||||||||
| Religion | Hindu | 14 (28) | 2.368 | 1 | 0.198 (NS) |
|||||
| Sikh | 35 (70) | |||||||||
| Others | 1 (2) | |||||||||
| Residence | Rural | 25 (50) | 2.368 | 1 | 1.000 (NS) |
|||||
| Urban | 25 (50) | |||||||||
| Monthly Income | <6323 | 27 (54) | 2.992 | 1 | 0.007 (HS) |
|||||
| 6327–18949 | 8 (16) | |||||||||
| 18943–31589 | 6 (12) | |||||||||
| 31591–47262 | 2 (4) | |||||||||
| 47266–63178 | 3 (6) | |||||||||
| 63182–126356 | 1 (2) | |||||||||
| >126360 | 3 (6) | |||||||||
| Occupation | Unemployed | 6 (12) | 2.368 | 1 | <0.001 (HS) |
|||||
| Elementary education | 3 (6) | |||||||||
| Plant and machine operators and assemblers |
17 (34) | |||||||||
| Craft and related trade workers |
12 (24) | |||||||||
| Skilled agricultural and fishery workers |
4 (8) | |||||||||
| Skilled workers and shop and market workers |
6 (12) | |||||||||
| Clerks | 2 (4) | |||||||||
| Total | 50 (100) | |||||||||
| Family structure | Joint | 23 (46) | 2.368 | 1 | 0.81 (NS) |
|||||
| Nuclear | 27 (54) | |||||||||
| Marital Status | Single | 21 (42) | 2.368 | 1 | 0.027 (NS) |
|||||
| Married | 26 (52) | |||||||||
| Divorced | 3 (6) | |||||||||
| Family History | Positive | 5 (10) | 2.368 | 1 | 0.108 (NS) |
|||||
| Negative | 45 (90) | |||||||||
| Lifestyle | Sedentary | 13 (26) | 2.368 | 1 | ||||||
| Moderate | 12 (24) | |||||||||
| High work performing | 5 (10) | |||||||||
|
Duration of
Illness(months) |
1–12 | 20 (40) | 2.368 | 1 | 0.002 (S) |
|||||
| 13–36 | 13 (26) | |||||||||
| 37–72 | 8 (16) | |||||||||
| 73–120 | 5 (10) | |||||||||
| >120 | 4 (8) |
As described in table 2, the chief complaints of the most of the patients (⩾3% of the total) were contamination and religious obsessions (36%), Cleaning/washing compulsion (26%), sexual obsessions (14%), religious obsessions (8%), contamination obsessions (6%), aggressive obsessions, and checking compulsions (4%; Table 2).
Table 2. Chief Complaints of the Patients w.r.t to YBOCS.
| Chief complaints | No of subjects (%) | |
| Aggressive obsessions | 2 (4) | |
| Contamination obsessions | 3 (6) | |
| Sexual obsessions | 7 (14) | |
| Cleaning/washing compulsions | 13 (26) | |
| Religious obsession | 4 (8) | |
| Contamination and religious | 18 (36) | |
| Miscellaneous | 1 (2) | |
| Checking compulsions | 2 (2) |
From baseline to Visit 7, an improvement in YBOCS score was reported in the majority of patients. At baseline, a majority of the patients were in a severe category (50%) on the YBOCS. While a low and similar proportion of the patients were in the moderate (28%) and extreme (20%) categories. Only 2 patients were in the mild category. While at Visit 7, a majority of the patients were under the mild (88%) category, and the rest of the patients (12%) were under the moderate category of YBOCS. The mean difference was statistically significant (p-value = <0.0001) between the YBOCS baseline and Visit 7 scores (Table 3).
Table 3. Comparison of the Distribution of Sample According to the YBOCS Categories at Baseline and Visit 7.
| YBOCS Scores No. of patients (%) |
||||||||
| Categories | Baseline | Visit 7 | Mean (SD) difference between the YBOCS baseline and Visit 7 scores |
p-value | ||||
| Mild | 1 (2) | 44 (88) | 16.94 (6.532) | <0.0001 | ||||
| Moderate | 14 (28) | 6 (12) | ||||||
| Severe | 25 (50) | 0 | ||||||
| Extreme | 10 (20) | 0 | ||||||
SD, standard deviation; YBOCS, Yale Brown Obsessive Compulsive Scale.
The YBOCS visit 1 scores were positively but not significantly correlated with any of the variables, while the YBOCS visit 7 scores were negatively but not significantly correlated with all the variables except with the BIAS scores. The YBOCS7 score was positively but not significantly correlated with the BIAS score. The total state guilt was significantly positively correlated with moral standard (p-value = 0.004), and TGI (p-value = 0.000) scores. The Total moral standard score was positively and significantly correlated with total state guilt (p-value = 0.004) and TGI (p-value = 0.000) scores, while negatively and significantly correlated with Total BIAS (p-value = 0.018) score. The total trait score was positively and significantly correlated with the TGI score. Total TGI score was positively and significantly (p-value = 0.000) correlated with the only total state, moral standard, and total trait guilt scores. Total BIAS score was negatively and significantly correlated with total moral standard (p-value = 0.018), while negatively and non-significantly correlated with the TGI and YBOCS total score. The TGI total score was positively and significantly (p-value = 0.000) correlated with total state guilt score, total moral standard, and total trait score; while negatively but not significantly correlated with YBOCS7 and total BIAS scores (Table 4).
Table 4. Correlation Between YBOCS1, Total State Guilt, Total Moral Standard, Total Trait Guilt, Total Guilt Inventory, BIAS, and YBOCS7 Scores.
| YBOCS1 | YBOCS7 | Total state guilt score |
Total moral standard |
Total trait score |
Total BIAS score |
TGI (SUM_S_ M_T_ GUILT) |
||||||||
| YBOCS1 | ||||||||||||||
| PC | 1 | 0.225 | 0.069 | 0.137 | 0.267 | 0.001 | 0.25 | |||||||
| Sig. (2-tailed) | 0.115 | 0.633 | 0.342 | 0.061 | 0.061 | 0.08 | ||||||||
| YBOCS7 | ||||||||||||||
| PC | 0.225 | 1 | −0.267 | −0.07 | −0.136 | 0.082 | −0.196 | |||||||
| Sig. (2-tailed) | 0.115 | 0.061 | 0.63 | 0.347 | 0.571 | 0.172 | ||||||||
| Total state guilt | ||||||||||||||
| PC | 0.069 | −0.267 | 1 | .401** | 0.213 | 0.046 | .615** | |||||||
| Sig. (2-tailed) | 0.633 | 0.061 | 0.004 | 0.137 | 0.749 | 0 | ||||||||
| Total Moral standard | ||||||||||||||
| PC | 0.137 | −0.07 | .401** | 1 | 0.213 | −.333* | .715** | |||||||
| Sig. (2-tailed) | 0.342 | 0.63 | 0.004 | 0.138 | 0.018 | 0 | ||||||||
| Total trait score | ||||||||||||||
| PC | 0.267 | −0.136 | 0.213 | 0.213 | 1 | −0.07 | .782** | |||||||
| Sig. (2-tailed) | 0.061 | 0.347 | 0.137 | 0.138 | 0.629 | 0 | ||||||||
| Total BIAS SCORE | ||||||||||||||
| PC | 0.001 | 0.082 | 0.046 | −.333* | −0.07 | 1 | −0.184 | |||||||
| Sig. (2-tailed) | 0.061 | 0.571 | 0.749 | 0.018 | 0.629 | 0.2 | ||||||||
| SUM_S_M_T_GUILIT | ||||||||||||||
| PC | 0.25 | −0.196 | .615** | .715** | .782** | −0.184 | 1 | |||||||
| Sig. (2-tailed) | 0.08 | 0.172 | 0 | 0 | 0 | 0.2 |
Pearson Correlation ** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed).
Discussion
This study examined the role of religiosity and guilt in symptomatology and outcome of OCD and it also addresses the notable gaps in the research examining the relationship between features of OCD symptomatology & outcome and religiosity and guilt. Fifty eligible OCD patients were enrolled in our study. Our research highlights the association between the religiosity and guilt connected with OCD in significant cases among Sikhs and Hindus. The reason for this observation could be the predominance of this population group in our area.19 The mean score on the YBOCS scale on the first and seventh visit was 28.34 ± 6.60 and 11.40 ± 3.33 respectively, which was statistically significant (p-value <0.001). Subjects had chief complaints in form of contamination and religious obsessions, Cleaning/washing compulsion, sexual obsessions, religious obsessions, contamination obsessions, aggressive obsessions, and checking compulsions in descending order. Predominantly in 36% of subjects had a mixture of contamination/religious obsessions and 26% of subjects had cleaning/washing compulsions. These results were in-line with the study conducted by Akhtar et al., 1975.17 Another study by Steketee reported that religious obsessions were reported in most of the patients (33%). Authors also reported that sexual obsessions were positively associated with religiosity.11
Our study found a positive correlation between OCD and guilt (r = 0.250) and negative correlation between OCD and religiosity (r = −0.028) and negative correlation between BIAS score and Total Guilt Inventory score (r = −0.184). These differences can be attributed to cultural factors and the fact that these factors contribute to promoting faith and spirituality from childhood onwards and leading to the development of the superego which is more punitive and harsh, which further has a role in the development of guilt. Further, the Hindu and Sikh religions being very flexible in terms of the punctuality of prayers, rituals, and cleanliness factors which can be considered as one of the preventive factors related to the symptomatology of OCD as compared to the Muslim population. Our arguments are in alliance with our results in comparison to previous literature where some strong relationship is observed between religiosity and OCD (e.g., Yorulmaz, Gençöz, and Woody, 2010). A good deal of this inconsistency is likely due to continued inadequate measurement of the construct of religiosity/spirituality and definition of religiosity as a religious observance, religious fundamentalism and label it as religiosity whereas others measure this construct in an extremely simplistic manner (e.g., using a single-item measure; Abramowitz et al., 2002 & Inozu et al., 2012).
This opens a new window for a precise construct of religiosity/ spirituality with OCD. The equivocal nature of the findings reflects religiosity is a potential sphere for the development of OCD phenomena rather than a specific determinant of this disorder. Cross-cultural research on OCD appears to demonstrate that the core phenomenology of OCD is very similar across cultures, although it appears that cultural factors (including religion) may affect obsession content (Fontenelle, Mendlowicz, Marques, & Versiani, 2004). Our study has found a negative correlation between OCD and religiosity (r= − 0.028) and the outcome on the YBOCS scale in such patients was encouraging. As compared where the correlation was higher the outcome was poor (Witzig et al., 2013).6,16,21 Although, few studies have demonstrated no relationship between religiosity and scrupulosity.14 The differences in the above results could be because of the low sample size and short follow-up of the patients i.e., 6 months only.
In our study, there was a negative correlation between religiosity and OCD (r = −0.028) and a positive correlation between Guilt and OCD (r = 0.250) on various scales used in the study i.e., YBOCS, BIAS, and TGI respectively. In addition to this, there was a positive correlation seen between the first visit YBOCS score and the Trait Guilt score (a sub-component of TGI), which was statistically significant (r = 0.267). Further, there was a negative correlation seen between the BIAS score and Total Guilt Inventory score, which was statistically significant (r = − 0.184). The outcome on the YBOCS was significantly improved after treatment although the religiosity score measured on the BIAS scale was higher in our study which is in contrast to previous literature (Abramowitz et al., 2004; Gonsalvez et al., 2010; Sica et al., 2002).20 A majority of the patients were improved from the severe category (50% at baseline) to mild (88% at follow-up) category after 6 months of treatment. The mean difference was statistically highly significant (p-value = <0.0001) between the baseline and 7th Visit YBOCS scores.
Therefore, it had been concluded from this study that religiosity and guilt has a considerable effect on the symptomatology and outcome of OCD.
Conclusion & Relevance
Our study found that religiosity and guilt have significant effects on the symptomatology and outcome of OCD. At baseline, OCD severity was positively correlated with religiosity and guilt, while after 6-month follow-up, OCD severity was negatively correlated with religiosity and positively correlated with guilt.
Acknowledgments
Authors are thankful to Baba Farid University Of Health Science, Faridkot, Punjab, India for providing the authors with all the necessary facilities and timely guidance.
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