International Journal of Clinical Medicine, 2013, 4, 479-484
Published Online November 2013 (
Open Access IJCM
Obsessive-Compulsive Cognitions, Symptoms and
Religiousness in an Iranian Population
Giti Shams1*, Irena Milosevic2
1Department of Psychiatry, Tehran University of Medical Sciences (TUMS), Roozbeh Hospital, Tehran, Iran; 2Department of Psy-
chology, Concordia University, Montreal, Canada.
Email: *, *,
Received August 26th, 2013; revised September 25th, 2013; accepted October 20th, 2013
Copyright © 2013 Giti Shams et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Individual differences in obsessive-compulsive (OC) behavior in various cultures appear to be associated with religios-
ity. The purpose of this study was to evaluate the role of religio n in OC symptoms and cognitions in distinctly low and
high religious groups from a normal community sample of 119 Iranian Muslims. Specifically, we compared the two
groups on OC cognitions and symptoms, and we examined the correlations between the cognitive and symptom meas-
ures within each group. There was a trend for the high religious group to produce greater scores than those in the low
religious group on the Obsessive Beliefs Questionnaire (OBQ) subscale of threat overestimation and resp onsibility. Fur-
thermore, participants that were more religious achieved significantly higher scores on the Penn Inventory of Scrupu-
losity and on its Fear of God subscale. Although a number of significant correlations were observed between OBQ and
Padua Inventory total and subscale scores, particularly in the low religious group, there was no conclusive relation ship
between religiosity and OC behavior and obsessional beliefs. Religion appears to be one more arena where OC symp-
toms expressed, rather than being a determinant of the disorder.
Keywords: OCD; OCCWG Scrupulosity; Cross-Culture
1. Introduction
A wealth of psychiatric research has examined the rela-
tionship between OCD and cu ltural and religious id entity
and practice. Several studies suggest that scrupulosity is
a common presentation of OCD [1,2], and previous re-
search suggests that patien ts’ religious denomination and
strength of religiosity can influence their OCD symptoms
[3,4]. Yet, despite the prevalence and recognition of
scrupulosity in OCD, relatively few studies have exam-
ined it in the coun tries with Muslim cultures.
In a study on the relationship between religiosity, reli-
gious obsessions and other clinical characteristics of
OCD, no significant differences were found in the overall
severity of obsessions and compulsions between patients
with or without religious obsessions [5]. No particular
relationship was found between religious practice or reli-
gious obsessions and any other particular type of obses-
sion or compulsion. Overall, their findings indicated that
there was no conclusive relationship between religiosity
and any other clinical features of OCD. Other studies,
however, have demonstrated links between OCD and re-
ligiosity in particular cultural groups. For example, reli-
gious compulsions were second only to contamination
and cleaning compulsions in a sample of patients from
Eastern Turkey [6 ]. A high proportion of r eligious obses-
sions is related to observance and blasphemy in a sample
of Muslim OCD patients [7]. The relationship between
religiosity and OC behavior was investigated in Israeli
Jews [8]. In their first study, no association was found
between religiosity and OC behavior, although religiosity
is related to some degree to perfectionism and to parental
attitudes toward upbringing. However, in their second
study, a significant difference was observed between
more religious and less religious groups on OC behavior,
as measured by the Maudsley Obsessional-Compulsive
Inventory ( M OCI).
Some studies have investigated the relationship be-
tween OC behavior and religious beliefs and practices in
normal individuals (non-OCD), with findings suggesting
that there is a relationship between religiosity and OC
*Corresponding a uthor.
Obsessive-Compulsive Cognitions, Symptoms and Religiousness in an Iranian Population
ideation and behavior. Other studies [9] indicated that
thought-action (TAF) significantly associated within the
Christian population [10] then developed an inventory of
religious OC symptoms and tested it on a sample of
American college students. They found that students who
identified themselves as highly devout scored high on
two scales of the inventory: Fear of Sin and Fear of
God’s Punishment. When comparing high, medium and
low levels of religiosity, [4 ] results suggest that measures
of control of thoughts and over-importance of thoughts
are associated with OC symptoms only in religious par-
ticipants. The authors concluded that religion might play
a role in obsessive-compulsive disorder phenomenology,
but it is plausible that a few aspects of religious teachings
(e.g. inflexibility and prohibition) linked to OC phenom-
ena. In sum, research with non-clinical samples has
found that certain OCD-relevant cognitive styles are re-
lated to religiosity. A tentative summary of these results
is that in the normal population, there is a relationship
between religiosity and OC beliefs and behavior. Despite
the prevalence and recognition of scrupulosity as a pres-
entation of OCD, relatively few studies have examined
its cognitive and symptoms correlates. Fear and intoler-
ance of uncertainty (often seen in individuals with scru-
pulosity) result in distorted perceptions of the boundary
between normal religious behavior and OC symptoms
[11], which may complicate cogn itive behavioral therapy.
A clear understanding of scrupulosity might facilitate the
development of more effective treatment strategies for
this particular presentation.
To date, there is no research investigating the associa-
tion between the degree of religiosity (low vs. high) with
OC cognitions and symptoms in participants from Iran, a
country in which 99% of the population is Muslim
(Shiae). The present study therefore conducted to further,
investigate these phenomena in distinctly low and high
religious groups from a normal community popu lation in
Iran. Specifically, we compared the groups on OC cogni-
tions, including responsibility/threat estimation, perfec-
tionism/certainty, and importance/control of thoughts,
and symptoms, including contamination, checking, ob-
sessional thoughts/impulses, and dressing/grooming com-
pulsions. The second aim of the present study was to
investigate the correlation between OC symptoms and
cognitions in each religious group. Finally, we also aimed
to describe the demographic characteristics of each of the
two religious groups.
2. Method
2.1. Participants
One hundred and nineteen participants (52 women and
67 men) recruited from the community in Tehran, the
capital of Iran. Participants ranged in age from 18 to 50
years (M = 34.89, SD = 10.70). All participants were
Muslim (Shiae).Participants were asked to indicate their
beliefs on Islam with answer options Muslim-non-Mus-
lim. However, the Muslims samples divided into two
degree of religiosity through selecting two groups with
distinct feature. A high degree of religiosity was consid-
ered as typical individuals who strictly obey Islam rules
like regular praying, fasting seriously and participating in
religious meeting hold in Masjid. A low degree of religi-
osity was identified in people who believed on God but
were not interested to obey Islam rules and regulations.
Individuals who did not pray regularly, Fasting or par-
ticipating in religious meeting hold in Masjid, catego-
rized as low degree of religiosity. The sample selection
carried out through oral questions. Participants asked to
indicate their religion background, with answer options
Muslim-non Muslim. Individuals who did not obey Is-
lamic rules excluded from the study. A brief description
of study purpose is given. Participation was voluntary.
All questionnaires completed in a pseudo-random order
and individually.
3. Measures
Obsessive Beliefs Questionnaire-44-Persian (OBQ-44-
Persian) [12]. The OBQ-44-Persian co nsists of 44 belief
statements considered characteristic of obsessive think-
ing [13,14]. Scale items represent six rationally deter-
mined subscales through corresponding to the key belief
domains in OCD. The subscales are Responsibility/
Threat Estimation (RT, 16 items), Perfectionism/Certain-
ty (PC, 16 items), and Importance/Control of Thoughts
(ICT, 12 items). Respondents indicate their general level
of agreement with items on a 7-point rating scale that
ranges from (-3) “disagree very much” to (0) “neutral” to
(+3) “agree very much”. For the current study, item re-
sponses transformed to a 1 to 7 scale, and subscale scores
calculated by summing across their respective items.
Padua Inventory—Washington State University
Revision (PI-WSUR) [15]. The PI-SWUR is a 39-item
self-report measure of obsessions and compulsions. Each
item is rated on a 5-point scale indicating the degree of
disturbance caused by the thought or behavior (0 = “not
at all” to 4 = “very much”). Items organized to measure
five content areas relevant to OCD, including Obses-
sional Thoughts about Harm to Self/Others (OTAHSO),
Obsessional Impulses to Harm Self/Others (OITHSO),
Contamination Obsessions and Washing Compulsions
(COWC), Checking Compulsions (CHKC), and Dress-
ing/Grooming Compulsions (DRGRC).
Penn Inventory of Scrupulosity (PIOS) [16]. The
PIOS is a 19-item self-report measure developed to as-
sess scrupulosity in the context of OCD (i.e., religious
obsessions). It consists of two subscales, one measuring
fears of having committed a religious sin (Fear of Sin;
Open Access IJCM
Obsessive-Compulsive Cognitions, Symptoms and Religiousness in an Iranian Population 481
e.g., “I am afraid of having sexual thoughts”), and the
other measuring fears of punishment from God (Fear of
God; e.g., “I worry that God is upset with me”). Items are
scored on a 5-point scale ranging from 0 (never) to 4
(constantly). Participants are also asked to indicate their
current religious affiliation and degree of religious devo-
tion on a scale from 1 (not at all devoted) to 5 (very
strongly devoted). Responses to the religious devotion
item have found strongly correlate with other aspects of
religious observance, such as frequency of attending reli-
gious worship services [16]. The PIOS has adequate
Psychometric properties in non-clinical samples [16] but
it has not studied in clinical groups.
4. Results
4.1. Statistical Analyses
Firs Comparison of demographic characteristics between
high and low religious groups done via Chi-square tests
of association, with the exception of age, which was
compared with an independent samples t-test. Independ-
ent t-tests also used to compare the more and less reli-
gious groups on OC cognitions, symptoms, and scrupu-
losity. Pearson correlation coefficients calculated be-
tween the OBQ-44, PI-WSUR, PIOS subscales.
The demographic characteristics of more and less reli-
gious participants are presented in Table 1. Women and
indiv iduals w ith inte rmediat e educa tion (Ba chelor’s d egree)
were found to be significantly more religious (p = 0.01).
4.2. Comparison of Groups on OC Cognitions,
Symptoms, and Scrupulosity
The two participant groups compared on their scores on
the OBQ-44, PI-WSUR and PIOS subscales and totals
(see Table 2). OBQ-44 total scores were higher among
highly religious participants. Moreover, the highly reli-
gious participants scored higher on the OBQ-44 RT and
ICT subscales but not on the PC subscale. However,
none of the differences reached statistical significance.
Participants who were low in religiosity scored higher on
PI-WSUR total and all of its subscales, except for Obses-
sional Impulses to Harm Self/Others and dressing/groom-
ing compulsion where the reverse was true, but again,
these differences were not statistically sign ificant. As for
the PIOS, highly religious participants achieved signifi-
cantly greater scores than less religious participants on
the total scale (p = 0.03), as well as on the Fear of God (p
= 0.01) subscale.
4.3. Correlations between Measures of OCD
Symptoms and Cognitions in More and Less
Religious Participants
In less religious participants, significant correlations ob-
Table 1. Demographic characteristics of more and less reli-
gious participants.
Mean (SD) Mean (SD) p-value
Age 35.35 (10.97) 29.27 (12.77) 0.02*
Count (%) Count (%) p-value
46 (68.7)
47 (90.4)
21 (31.3)
5 (9.6)
Years of Education
Dip /lower
B. Deg
34 (68)
52 (91.2)
7 (58.3)
5 (8.8)
5 (41.7)
Occupation Stu
18 (66.7)
65 (83.3)
10 (71.4)
9 (33.3)
13 (16.7)
4 (28.6)
Note. MR = More religious; LR = less religious; Dip = Diploma; B. Deg =
Bachelor’s Degree M.Deg = Master’s Degree Stu = Student Job/S-at-h =
Table 2. Comparison of more and less religious groups on
oc cognitions, symptoms, and scrupulosity.
MR (n = 93)
Mean (SD) LR (n = 26)
Mean (SD) Total
Mean (SD)p-value
OBQ-Total 194.24 (35.96)182.65 (34.83) 191.71 (35.89)0.15
OBQ-RT 71.20 (15.29)64.58 (14.70) 69.76 (15.35)0.06
OBQ-PC 73.22 (14.31)71.54 (14.70) 72.85 (14.35)0.60
OBQ-ICT 49.82 (11.61)46.54 (9.93) 49.10 (11.31)0.19
PI-WSUR-Total28.85 (17.79)30.00 (21.56) 29.10 (18.59)0.78
COWC 9.16 (6.02) 9.46 (6.45) 9.23 (6.09)0.83
CHKC 10.90 (8.86)11.65 ( 10.10) 11.07 (9.11)0.71
OTAHSO 3.77 (4.60) 3.69 (3.23) 3.76 (4.32)0.93
OITHSO 1.12 (2.33) 1.85 (1.85) 1.28 (2.24)0.14
DRGRC 3.89 (3. 65 ) 3.35 (3.10) 3.77 (3.53)0.49
PIOS-Total 33.11 (15. 52)2 5.23 (18.80) 31.39 (16.53 )0.03*
PIOS-Fear of
God 14.67 (6.48)9.54 (7.41) 13.55 (6.99)0.01*
PIOS-Fear of
Sin 18.44 (10.02)15.69 (11.91) 17.84 (10. 47)0.24
Note. MR = More religious; LR = Less religious. OBQ = Obsessive Beliefs
Questionnaire. RT=Responsibility/Threat Estimation; ICT = Importance/
Control of Thoughts; PC = Perfectionism/Certainty; PI-WSUR = Padua
Inventory–Washington State University Revision; COWC = Contamination
Obsessions and Washing Compulsions; CHKC = Checking Compulsions;
OTAHSO = Obsessional Thoughts About Harm to Self/Others; OITHSO =
Obsessional Impulses to Harm Self/Others; DRGRG = Dressing/Grooming
Compulsions ; PIOS = Penn Inventory of Scrupulosity.
served between the OBQ-44 total and all subscales with
the PI-WSUR and its checking compulsions and obses-
sive thoughts of harm to self/others subscales (see Table
3). For this group, no significant correlations were ob-
served between the OBQ-44 total and its subscales with
the dressing/grooming compulsions scores on the PI-
WSUR. There were significant correlations in partici-
Open Access IJCM
Obsessive-Compulsive Cognitions, Symptoms and Religiousness in an Iranian Population
Table 3. Pearson correlations between measures of ocd
symptoms and cognitions in more and less religious par-
OBQ-Total 0.29** 0.58** 0.23* 0.41* 0.16 0.59**
OBQ-RT 0.30** 0.55** 0.23* 0.42* 0.19 0.55**
OBQ-PC 0.18 0.53** 0.20 0.35 0.03
OBQ-ICT 0.28** 0.44* 0.18 0.30 0.20
OBQ-Total 0.17
0.57** 0.19 0.52** 0.31** 0.36
OBQ-RT 0.19
0.55** 0.13 0.39 0.33** 0.35
OBQ-PC 0.02
0.47* 0.17 0.51** 0.32** 0.29
OBQ-ICT 0.26* 0.47* 0.20 0.48** 0.14 0.31
Note. MR = More religious; LR = Less Religious; OBQ = Obsessive Beliefs
Questionnaire; RT = Responsibility/Threat Estimation; ICT = Importance/
Control of Thoughts; PC = Perfectionism/Certainty; PI-WSUR = Padua
Inventory–Washington State University Revision; COWC = Contamination
Obsessions and Washing Compulsions; CHKC = Checking Compulsions;
OTAHSO = Obsessional Thoughts about Harm to Self/ Others; OITHS O =
Obsessional Impulses to Harm Self/Others; DRGRG = Dressing/Grooming
pants that are more religious, on OBQ-44 total and sub-
scale scores with checking compulsions scores in PI-
There were, however, no significant correlations be-
tween the OBQ-44 total and all subscales with the PI-
WSUR checking compulsions and obsession impulses to
harm self/others PI-WSUR subscales in this group (see
Table 3).The results showed the most of statistically sig-
nificant correlations belong to less religious participants.
5. Discussion
The present study is the first to address the relationship
between cognitions and symptoms of OCD in a low and
high religious normal community sample of Muslim in-
dividuals in Iran. Our data indicated no significant dif-
ferences in high religious participants as compared to
low religiosity on OBQ-RT, OBQ-PC, and OBQ-ICT.
On the other hand, less religious participants scored higher
on PI-WSUR and all its subscales, except for dressing/
grooming compulsions, compared to highly religious par-
The present findings which were opposite to other [4]
results showed that participants with a low degree of re-
ligiosity endorsed greater importance of thoughts com-
pared to a highly religious group. The authors also re-
ported that religion was a factor potentially linked to
OCD. In the particular situation of Iran, individuals with
a high or medium degree of religiosity showed higher
levels of obsessionality and OC cognitions as compared
to individuals with a low degree of religiosity of the
same age, education, and gender. OC cognitions are sys-
tematically related to impaired mental control only in
religious individuals. The two cognitive domains that
best discriminated between religious individuals and in-
dividuals who were low in religiosity (control and im-
portance of thoughts) were associated with OC symp-
toms only in religious participants. The domain of per-
fectionism, as assessed by the OBQ, was associated with
the PI-WSUR total score also only in religious partici-
pants. Moreover, highly superstitious participants scored
higher than less superstitious participants did on the
OBQ threat estimation scale.
It is important to note that the Obsessive-Compulsive
Cognitions Working Group (OCCWG) was interested in
meaningful and theoretically consistent differences
across three OCD, anxious and normal groups. In an ini-
tial study in Iran [17], participants with OCD, non-OCD
anxiety disorders, and those from a community sample
strongly endorsed beliefs related to the importance and
control of thoughts. Both the OC and anxiety control
patients scored higher than community controls on RT
and PC, although there were no significant differences
between the two patient populations in these domains.
Therefore, the domain that appeared to be specific to
OCD was ICT.
In the present study, highly religious individuals ob-
tained a significantly higher total score on the PIOS, as
well as on the Fear of God subscale. It is not clear
whether different religions have different effects on ob-
sessive-compulsive psychopathology. All religions by
their nature involve rituals to some extent, perhaps some
more than others. A large Egyptian sample with religious
obsessions, reported that their Christian patients, who
constituted 10% of the sample, seemed to suffer as much
as their Muslim patients from obsessions with religious
themes [18]. However, they [19] did not report any dif-
ferences between Catholic and other OCD patients in
terms of religious obsessions, and they did not find any
associations between religious obsessions, overall illness
severity, and a self-reported level of religiosity. In fact, a
variety of symptoms related to religious thoughts are
more prevalent in clinical populations from countries in
which religion occupies the central core of society, par-
ticularly in Muslim and Jewish Middle Eastern culture,
by contrast to clinical populations in the West.
Superstition may be a predisposing factor for general
rather than specific psychopathology because overesti-
mation of threat appears to be a feature of almost all
anxiety disorders. Religion might play a role in OCD
phenomenology, particularly in individuals whose relig-
ion is a prominent part of their cultural values [4]. Relig-
ion appears not to be a distinct domain o f OCD; rather it
is the context for the disorder in very religious patients
[20]. Despite the similarities between obsessive-com-
pulsive psychopathology and religious phenomena, it
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Obsessive-Compulsive Cognitions, Symptoms and Religiousness in an Iranian Population 483
does not seem to be a strong relationship between relig-
ion and OCD [5]. Instead of being a determinant of the
disorder, religion appears to be just another area where
OCD expresses itself. Clinicians should be sensitive to
the fact that religious obsessions may be more prevalent
in certain cultures with which they may not well acqu aint.
Nevertheless, religious obsessions should be treated as
obsessions rather than religious phenomena.
While a consensus seems to have reached on the uni-
versality of the form of OCD symptoms, the content of
the obsessions and compulsions appears to differ across
cultures. There is a risk that OCD may be missed if it’s
manifested in behaviors which are considered appropri-
ate within a religions context. On the other hand, reli-
gious obsessions are common, more so when the variety
of obsessions experienced is greater, but that they are not
related to the severity of other OCD symptoms, suggest-
ing that religious obsessions are an embellishment of
disorder rather than a determinan t [21]. Religious aspects
of OCD have also been noted by authors who study ob-
servant Orthodox Jews [20,22], and some Catholics [23].
The frequency with which different OCD themes played
out in life’s secular and religious spheres may vary with
the intensity of religious observance within cultural
groups. Religious obsessions were found to be quite
common in a small sample of ultra-Orthodox Jewish pa-
tients [20] and in three samples of Muslim patients, one
in Saudi Arabia [24], one in Bahrain [7] and one in Egypt
[18], but not in a fourth form Turkey [25]. However,
there is no indication that groups with more heavily reli-
gious have higher incidence of OCD [26]. Thus, it may
be concluded that culture has an effect on the way OCD
manifests itself but it does not increase its prevalence in
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