Scrupulosity disorder: an overview and introductory analysis

Movement Toward Dimensional Symptom Models of Comorbid Obsessive-Compulsive Disorder and Eating Disorders

Obsessive-compulsive disorder (OCD) and eating disorders (EDs) are highly comorbid. Despite the high comorbidity, there is little understanding of why these disorders coexist and even less research on how to best treat this co-occurrence. In this article, we review the literature on comorbid OCD-ED and discuss potential underlying shared mechanisms, including anxiety/avoidance, perfectionism, intolerance of uncertainty, habit formation, disgust, shame and guilt, rumination, metacognitive beliefs, and shared biological characteristics. We then discuss prior models of OCD-ED comorbidity and shift the perspective from latent or categorical models to dimensional symptom models (e.g., network models). We describe how dimensional symptom models could advance the conceptualization, treatment, and prevention of comorbid OCD-ED. Next, we discuss how idiographic (one-person) symptom models could advance personalized treatment and provide a treatment example. Finally, we discuss future research needed to advance the field and improve treatment outcomes.

From Doubt to Direction: Untangling Pediatric Scrupulosity

Background: Up to 33% of individuals with obsessive-compulsive disorder (OCD) have scrupulosity symptoms, although less is known regarding the prevalence rates in youth, specifically. Scrupulosity translates to "fearing sin where there is none" and describes pathological guilt and distress related to religion and morality. Disentangling scrupulosity from true religious beliefs and actions may be difficult in youth for a number of reasons, including the nature of youth as a time of developing independent identities and values, expected ritualistic behavior (e.g., confession, ritualistic cleansing), scrupulosity being reinforced in some religious communities, and the discomfort or inexperience of clinicians with both these symptoms and various belief systems. The literature suggests limited knowledge of scrupulosity among mental health providers, including pediatric clinicians, and apprehension to discuss or target scrupulous beliefs and behaviors. Apprehension may be enhanced for providers working with youth populations, particularly given broader misconceptions about the efficacy and safety of gold-standard interventions. Objectives: This narrative review with practice guidelines examines the existing literature related to pediatric scrupulosity and its challenges and describes evidence-based treatments for scrupulosity in pediatric populations. Recommendations for clinical practice and research are discussed.

Obsessive-Compulsive Disorder with a Religious Focus: An Observational Study

Background: Obsessive-compulsive disorder (OCD) is a psychiatric disorder with poorly detailed subtypes/dimensions, such as religious OCD (ROCD). To date, little is known about ROCD characteristics. This work aimed to describe the sociodemographic and clinical characteristics, along with the religiosity and spirituality, of Lebanese Muslim citizens diagnosed with OCD and exhibiting religious symptoms. Methods: Participants were Lebanese Muslims, outpatients with OCD and religious symptoms, aged 18 or above, who could complete a questionnaire. Exclusion criteria were as follows: other psychiatric disorders and cognitive or physical impairments preventing participation. They completed a questionnaire including the 25-item Arabic Scale of Obsessions and Compulsions (10 questions addressing obsessions, 10 questions addressing compulsions, and 5 filler items, all of which were rated on a 4-point Likert scale, with higher total scores indicating increasing severity), the 26-item Spiritual Involvement and Beliefs Scale (rated on a 5-point Likert scale, with higher scores indicating higher spirituality), and questions assessing sociodemographic, clinical, and religiosity variables. Results: Fifty adults (62% females, 52% aged between 18 and 29 years) completed the study. They had mild (26%), moderate (48%), and severe (26%) OCD symptoms. The majority attended religious school at least at one point in their life and described a moderate to very high degree of self-religiosity and parental religiosity. Group comparisons (patients with mild vs. moderate vs. severe OCD symptoms) showed significant differences with regard to a family history of psychiatric disorders (p = 0.043), the frequency of self-questioning if they prayed correctly (p = 0.005), a higher rating of partial ablution repetition (p = 0.006), and the frequency of partial ablution repetitions (p = 0.041). No significant group differences were noted with regard to sociodemographic or spirituality outcomes. The prevalence of religious doubts (i.e., self-questioning if praying correctly) and specific rituals (partial ablution repetition) among severe OCD patients were 100% (13/13) and 77% (10/13), respectively. Conclusions: The results suggest a link between specific religious practices and OCD severity, underscoring the need for culturally sensitive approaches in diagnosing and treating ROCD.

Religious scrupulosity and early maladaptive schemas: a network analysis

Scrupulosity is treated as a particular presentation of the symptomatology characteristic for obsessive-compulsive disorder (OCD). However, typical treatment of OCD (e.g. cognitive-behavioral therapy) is less effective in the case of religious scruples. Recently, schema therapy has appeared as an alternative effective treatment in obsessive-compulsive symptomatology. The present study investigated the associations between early maladaptive schemas (EMSs) and scrupulosity in a non-clinical sample of 376 poles. The participants assessed their EMSs with the Young Schema Questionnaire 3 - Short Form and their scrupulosity with the Pennsylvania Inventory of Scrupulosity. We used network analysis to control for the EMS interconnectivity. We showed that accounting for the interactions within the EMSs, three schemas, namely, Punitiveness, Subjugation, and Enmeshment/Undeveloped Self, were positively correlated with scrupulosity. Given the central position of the Negativity/Pessimism schema in the examined network, we suggested that activation of this schema could be indirectly correlated to scruples via an escalation of activation to the Punitiveness, Subjugation, and Enmeshment schemas. The findings suggest that dependency and fear of rejection problems (present in Subjugation and Enmeshment EMSs) and over-compensation by perfectionism (present in Punitiveness EMS) could be addressed in the treatment of scruples.

"A dim recognition." Religion as a font of psychological innovation

While religion constituted one of the main topics of interest for early social scientists, faith traditions have silently slipped from this central role. When religion now appears in psychological research, it is usually relegated to the position of either the object of psychological investigation (which psychology purports to "explain") or a static piece in the empirical puzzle (as one variable among many when explaining clinical or social outcomes). In either case, religion is generally no longer seen as an equal partner to the social sciences in our attempts to better understand of the human condition. However, there are and have been voices within psychology that see this as unnecessarily myopic. James Jackson Putnam (1846-1918), an early supporter of the emerging field of psychoanalysis, advocated that psychology take seriously philosophy, metaphysics, and religion. Putnam's objections to the narrowing of our view of human life in the spirit of scientism fell largely on deaf ears, and his call for psychology to include that which lies beyond the walls of empirical naturalism and reductionism remains relevant today. In as far as theoretical innovation in psychology is more of a creative recognition than true scientific discovery, philosophy and religion constitute tremendously rich, and unfortunately underappreciated, fonts of inspiration. Putnam saw in religion the "dim recognition" of "the creative spirit of the universe." We briefly reflect on the example of obsessive-compulsive disorder and the much older religious concept of scruples, including approaches to mindfulness. This example is suggestive of the richness of psychological insights to be found in religion.

Development of the scrupulosity inventory: A factor analysis and construct validity study

BACKGROUND AND OBJECTIVES

Scrupulosity, despite its considerable prevalence and morbidity, remains under-investigated. The present study develops and examines the psychometric properties of a comprehensive assessment tool, the Scrupulosity Inventory (SI).

METHODS

The SI, along with other measures of obsessive-compulsive disorder (OCD) and perfectionism, were administered to a sample (N = 150) of college undergraduates similar in size to other scale development studies of related measures. We conducted exploratory and confirmatory factor analyses of the SI, examined its convergent and divergent validity, and assessed its ability to predict categorical diagnoses of scrupulosity using a receiver operator characteristic analysis.

RESULTS

We found a well-fitting confirmatory bifactor model (RMSEA = 0.049) with a strong general Scrupulosity factor ( [Formula: see text] ) and specific factors for Personal Violations ( [Formula: see text] ), Ritualized Behavior ( [Formula: see text] ), Interference with Life ( [Formula: see text] ), and Problem Pervasiveness ( [Formula: see text] ). As predicted, we also found the strongest convergence (r = 0.63) between the SI and the Penn Inventory of Scrupulosity (PIOS), intermediate convergence (r = 0.54) between the SI and Perfectionism Inventory (PI), and weaker convergence (r = 0.47) between the SI and YBOCS. Finally, we found that a categorical diagnosis of scrupulosity was highly predicted by the SI (AUC = 0.84), less well-predicted by the PIOS (AUC = 0.75) and less well predicted by the YBOCS (AUC = 0.69).

LIMITATIONS

This study was conducted among a sample of undergraduates at a religiously affiliated university.

CONCLUSIONS

These results suggest utility in using the SI to measure the severity of scrupulosity symptoms and that scrupulosity and OCD may present significantly different clinical features.

A Case Report of Scrupulosity Presenting as Catatonia in a Patient With Both OCD and OCPD

We present the case of a woman in her 40s with a history of hypothyroidism, a differential diagnosis of major depressive disorder with psychotic features versus bipolar I disorder, catatonia, and anorexia nervosa. The patient was admitted to the hospital for poor oral intake, mutism, and social withdrawal. Administration of lorazepam successfully treated these presenting symptoms. However, on subsequent days, she was found to be reading the Bible almost constantly during waking hours, at the expense of engaging in treatment or interacting with others. The patient's history and presentation supported the idea that her hyper-religiosity stemmed not from bipolar disorder or psychosis, as previously thought, but rather from a subtype of obsessive-compulsive disorder referred to as scrupulosity. This report summarizes the characteristics of scrupulosity and discusses this potentially deceptive mimic of more commonly seen conditions.

A New Scrupulosity Scale for the Dimensional Obsessive-Compulsive Scale (DOCS): Validation With Clinical and Nonclinical Samples

Scrupulous obsessions are a prominent presentation of obsessive-compulsive disorder (OCD). Previous conceptualizations of scrupulosity have indicated that it belongs to the unacceptable thoughts dimension, which pertains to sexual, violent, and religious obsessive themes. However, research suggests that scrupulous symptoms may differ from other unacceptable thoughts symptoms, necessitating the need for targeted and thorough assessment. We added a Scrupulous or Religious Thoughts subscale (DOCS-SR) to the Dimensional Obsessive-Compulsive Scale (DOCS) and tested its factorial structure, psychometric properties, and clinical correlates in a nonclinical and clinical sample. In the first study, nonclinical participants (N = 203) completed the DOCS-SR, which was subjected to an exploratory factor analysis. Analyses revealed that the DOCS-SR reflected a one-factor solution and possessed acceptable internal consistency, as well as strong convergent validity with clinical correlates of OCD. In the second study, we administered the DOCS, as well as the DOCS-SR to a clinical sample (N = 314). An exploratory factor analysis and confirmatory factor analysis both suggested that the four subscales and additional DOCS-SR represented a five-factor solution. Internal consistency and convergent validity were strong. The DOCS Unacceptable Thoughts subscale and the DOCS-SR shared a moderate correlation but evidenced differences in associations with other correlates. This suggested both convergent and divergent validity. Collectively, our results support the utility of examining the individual components of the unacceptable thoughts dimension of OCD for effective assessment and treatment planning.

Discerning Motivational Interviewing through a spiritual lens-discovering a Christian MI archetype and native MI language

An overarching conceptual perspective on motivational interviewing (MI) captures how it evokes intrinsic motivation for change by relying on four key elements: establishing vision, exploring discrepancy, and building efficacy, which coalesce to resolve for change. We suggest that the Christian narrative and doctrines of creation, fall, and redemption, motivating repentance resolve, invoke these same motivating processes. In this paper we explore these parallels between MI and Christian doctrine and use empirical literature to suggest how secular and religious counselors can enhance their efforts to evoke intrinsic motivation for change with religious clients by employing their "native language" within this framework of MI process.

Clinical features of scrupulosity: Associated symptoms and comorbidity

OBJECTIVE

Scrupulosity is a manifestation of obsessive-compulsive disorder (OCD) characterized by religious or moral core fears. Clinicians often struggle to treat scrupulosity, which may be associated with several features known to predict poor treatment outcome. The purpose of this study was to examine these features in participants with scrupulous OCD, contamination OCD, and healthy controls.

METHOD

A total of 68 participants (57.4% women, age_mean  = 34.01) completed diagnostic interviews, and measures of symptoms and quality-of-life.

RESULTS

Relative to comparison groups, scrupulous participants had higher rates of obsessive-compulsive personality disorder, more severe schizotypal symptoms, and more severe symptoms of depression. In addition, OCD severity was strongly associated with poor insight in the scrupulous group. Both OCD groups reported poorer quality of life than did healthy controls.

CONCLUSIONS

Clinicians working with scrupulous individuals may enhance the efficacy of treatment in this challenging population by assessing carefully for these features, and incorporating treatment elements that address them.

Neuroticism and Religiosity: The Role of Obsessive Beliefs, Thought-Control Strategies and Guilt in Scrupulosity and Obsessive-Compulsive Symptoms Among Muslim Undergraduates

Neuroticism and religiosity are distal vulnerability factors for OCD phenomenon. The present study aimed to examine the roles of obsessive beliefs (OBs), thought-control strategies, and guilt in the relationship between these vulnerability factors and obsessive-compulsive symptoms (OCSs), specifically scrupulosity symptoms in a Muslim sample via SEM. The sample consisted of 273 university students who filled out a set of questionnaires. The results indicated that neuroticism and the degree of religiosity predict OBs that are positively associated with guilt and self-punishment both of which predict scrupulosity and other OCSs. Findings of the present study were discussed in the context of the related literature.

Obsessive-compulsive disorder in children and adolescents: epidemiology, diagnosis and management

Obsessive-compulsive disorder (OCD) can be found in about 4% of the general population and is characterized by various compulsions and obsessions that interfere with the person's quality of life from a mild to severe degree. The following discussion reflects on current concepts in this condition, including its epidemiology and etiologic underpinnings (behavioral, neurological, immunological, gastroenterological, as well as genetic). The interplay of PANS and PANDAS are included in this review. In addition, the core concepts of OCD diagnosis, differential diagnosis, and co-morbidities are considered. It is stressed that the quality of life for persons with pediatric OCD as well as for family members can be quite limited and challenged. Thus, principles of management are presented as a guide to improve the quality of life for these persons as much as possible.

Comorbidity, Parental Psychopathology, and Accommodation in the Treatment of Pediatric Obsessive-Compulsive Disorder: A Case Study

This article discusses the treatment of a young person with obsessive-compulsive disorder (OCD) characterized primarily by symptoms of physical and mental contamination, as well as religious obsessions. The treatment was complicated by several factors that will be reviewed and addressed. First, this client had a comorbid diagnosis of attention-deficit/hyperactivity disorder. Second, the young client's mother was also diagnosed with OCD and had a significantly anxious presentation. This impacted treatment in two primary ways. One important way treatment was complicated was that the client frequently attempted to manage her mother's emotions by underreporting her own distress at times. The other implication of the mother's diagnosis was that it became difficult to involve her in the treatment of her daughter and reduce her accommodation of her daughter's symptoms. The manner in which these complicating factors were addressed in the successful treatment of this client by adapting evidence-based practice will be presented as a guide for clinicians facing similar challenges.

Imams’ Experience With and Response to Mosque-Goers With OCD Scrupulosity

The experience of obsessive-compulsive disorder (OCD) symptoms that have a religious theme is common. Recent research has found that religious participants with religious OCD symptoms frequently turn to religious advisors, such as imams or clergy, for help to understand and alleviate their symptoms. As such, the advice provided by imams or clergy may have an important impact on the response of the person seeking help. This study examined the attitudes, beliefs and experiences of 64 Muslim imams with mosque-goers who had religious OCD symptoms, particularly scrupulosity. This study also examined imams’ familiarity with first-line psychological treatments for OCD such as Exposure and Response Prevention (ERP). Sunni imams from Australia and Shia imams from Iran completed an online survey based on the research of Deacon, Vincent, and Zhang (2012), which was conducted with Christian clergy in the United States. Results showed that the majority of imams were unfamiliar with scrupulosity as a possible symptom of a mental health problem, such as OCD, and with ERP as a recognised treatment for OCD. While 37% of participants reported having been approached by mosque-goers for help with scrupulosity, only 9% referred mosque-goers to mental health professionals, and only one imam reported having referred a mosque-goer for ERP. Sunni imams located in Australia were more likely to provide advice inconsistent with the ERP approach and were also significantly less likely than Shia imams located in Iran to recommend referral to a mental health professional who was not affiliated with their own religious denomination. Finally, Sunni imams had significantly higher scores than Shia imams on Thought Action Fusion (TAF) subscales. Results of multiple regression analysis revealed that TAF explained a considerable amount of the variance related to ERP-inconsistent advice. Research implications and limitations are discussed.

Acceptance and commitment therapy for a case of scrupulosity-related obsessive-compulsive disorder

Acceptance and commitment therapy (ACT) is a modern form of cognitive behavior therapy (CBT) with growing support for treating obsessive-compulsive disorder (OCD). We present a case wherein a client presented with scrupulosity-related OCD. We briefly review scrupulosity, explain the theory behind ACT, and present a case, the treatment process, and desired outcomes. Exposure and response prevention (ERP) is described from an ACT perspective and discussed as an option for people with OCD who may be reluctant to engage in more traditional forms of ERP.

Pornography, Religion, and Parent-Child Relationship Quality

Frequent pornography use is often negatively associated with marital quality. Recent research has argued that this negative association is particularly strong for those who are embedded in religious communities, likely due to the greater stigma and shame associated with viewing pornography. In order to test and extend this theory, the current study examined how religious service attendance moderates the link between parents' pornography consumption and four measures of parent-child relationship quality. Analyses of 2006 Portraits of American Life Study data (N = 2610) revealed that greater pornography viewing predicted negative outcomes on two out of four measures of parent-child relationship quality, while religious service attendance was associated with more positive parent-child relationship outcomes. Interaction effects, however, affirmed that the negative association between porn viewing frequency and three parent-child relationship outcomes was stronger for participants who attended religious services more often. Analyzing fathers (N = 771) and mothers (N = 904) separately revealed that the observed relationships held more consistently for fathers than mothers. Evidence for directionality was presented by incorporating re-interview data from 2012. While pornography use may be negatively associated with some aspects of parent-child relationship quality, this association was particularly strong for those embedded within religious communities, possibly owing to greater attendant guilt and shame.

Does Viewing Pornography Diminish Religiosity Over Time? Evidence From Two-Wave Panel Data

Research consistently shows a negative association between religiosity and viewing pornography. While scholars typically assume that greater religiosity leads to less frequent pornography use, none have empirically examined whether the reverse could be true: that greater pornography use may lead to lower levels of religiosity over time. I tested for this possibility using two waves of the nationally representative Portraits of American Life Study (PALS). Persons who viewed pornography at all at Wave 1 reported more religious doubt, lower religious salience, and lower prayer frequency at Wave 2 compared to those who never viewed porn. Considering the effect of porn-viewing frequency, viewing porn more often at Wave 1 corresponded to increases in religious doubt and declining religious salience at Wave 2. However, the effect of earlier pornography use on later religious service attendance and prayer was curvilinear: Religious service attendance and prayer decline to a point and then increase at higher levels of pornography viewing. Testing for interactions revealed that all effects appear to hold regardless of gender. Findings suggest that viewing pornography may lead to declines in some dimensions of religiosity but at more extreme levels may actually stimulate, or at least be conducive to, greater religiosity along other dimensions.

The rise of moral emotions in neuropsychiatry

Clinical psychopathology has largely ignored the developments in the field of social neuroscience. The so-called moral emotions are a group of affective experiences thought to promote cooperation, group cohesion, and reorganization. In this review, we: (i) briefly describe a provisional taxonomy of a limited set of moral emotions and their neural underpinnings; and (ii) discuss how disgust, guilt, anger/indignation, and shame/embarrassment can be conceptualized as key affective experiences in different neuropsychiatric disorders. Based on a concise review of the literature linking moral emotions, psychopathology, and neuropsychiatry, we have devised a simple and preliminary scheme where we conjecture how specific moral emotions can be implicated in some categories of DSM-5 diagnoses, potentially helping to bridge psychopathology and neurobiologically plausible variables, in line with the Research Domain Criteria initiative. We hope this stimulates new empirical work exploring how moral emotional changes and their underlying neurobiology can help elucidating the neural underpinnings of mental disorders.

Prayer in Response to Negative Intrusive Thoughts: Closer Examination of a Religious Neutralizing Strategy

Few studies have systematically examined the covert neutralizing strategies that serve to maintain and exacerbate the frequency and distress related to intrusive thoughts. Given the lack of research in this area, this study aimed to highlight development and maintenance factors for one such strategy, compensatory prayer, to inform assessment and treatment of related obsessional phenomena. We used a multimethod approach to examine the predictors and function of prayer when it is used in response to negative intrusive thoughts. Participants were 85 undergraduate students (ages 18–55 years) who self-identified with a branch of Christianity. In addition to self-report measures, participants were administered an in vivo negative thought induction and were subsequently asked about their use of compensatory prayer behaviors. Results indicated that religiosity, intrinsic religious motivation, and moral thought–action fusion (TAF) positively predicted the use of prayer, with moral TAF emerging as a unique predictor and a complete mediator between religiosity and the use of prayer. Regarding the function of prayer, results indicated that when prayer is used maladaptively (i.e., negative coping style), it is associated with higher scores on religious measures and moral TAF, as well as more frequent engagement in prayer, and a greater reduction in anxiety postprayer. Surprisingly, likelihood TAF was not found to be related to the use or function of prayer. Results are discussed in terms of certain religious teachings and TAF-related beliefs, neurobiological explanations for our pattern of findings, and clinical implications for religious-related intrusive thoughts. Future directions and limitations are also discussed.

All in the Family

Obsessive-compulsive disorder (OCD) is common in children with rates of 1% to 4% in children and adolescents. A prominent first-line treatment for pediatric OCD is cognitive-behavioral therapy (CBT) using exposure and response prevention (ERP). However, it has also been suggested that family therapy be used as an adjunct treatment in pediatric OCD cases, as family members often accommodate or contribute to the maintenance of OCD symptoms. The following case study reviews the successful treatment of a 7-year-old with comorbid OCD and oppositional defiant disorder, in which traditional CBT and ERP for OCD was integrated with family-based approaches utilizing a family systems theory framework.

Acceptance and Commitment Therapy as a Treatment for Scrupulosity in Obsessive Compulsive Disorder

This study evaluated acceptance and commitment therapy (ACT) for scrupulosity-based obsessive compulsive disorder (OCD). Five adults were treated with eight sessions of ACT, without in-session exposure, in a multiple baseline across participants design. Daily monitoring of compulsions and avoided valued activities were tracked throughout the study. The Obsessive Compulsive Inventory–Revised, Yale–Brown Obsessive Compulsive Scale (Y-BOCS), Penn Inventory of Scrupulosity, Beck Depression Inventory–II, Quality of Life Scale, Santa Clara Strength of Religious Faith Questionnaire, and the Acceptance and Action Questionnaire–II were completed at pretreatment, posttreatment, and 3-month follow-up. The Treatment Evaluation Inventory was completed at posttreatment. Average daily compulsions reduced as follows: pretreatment = 25.0, posttreatment = 5.6, and follow-up = 4.3. Average daily avoided valued activities reduced as follows: pretreatment = 6.0, posttreatment = 0.7, and follow-up = 0.5. Other measures showed similar patterns. Religious faith only slightly declined: 4% at posttreatment and 7% at follow-up. Treatment acceptability was high.

Scrupulosity: a unique subtype of obsessive-compulsive disorder

The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed.

Moral thought-action fusion and OCD symptoms: the moderating role of religious affiliation

The empirical literature on the relationship between moral thought-action fusion (TAF) and obsessive-compulsive disorder (OCD) is characterized by mixed findings. Previous studies have reported religious group differences in moral TAF and the relationship between moral TAF and religiosity. In light of those studies and considering the apparent role of moral TAF in scrupulosity, the purpose of this investigation was to evaluate the possible role of religion as a moderator of the relationship between moral TAF and OCD symptoms. The results revealed that (a) Christians endorsed higher levels of moral TAF than did Jews independent of OCD symptoms; (b) religiosity was correlated with moral TAF in Christians but not in Jews, suggesting that Christian religious adherence is related to beliefs about the moral import of thoughts; and (c) moral TAF was related to OCD symptoms only in Jews. That is, for Christians, moral TAF was related to religiosity but not OCD symptoms, and for Jews, moral TAF was related to OCD symptoms but not religiosity. These results imply that moral TAF is only a marker of pathology when such beliefs are not culturally normative (e.g., as a function of religious teaching or doctrine).

Religious delusions in an evangelical Christian woman with anorexia nervosa

This case report describes the history and hospital course of a 42-year-old devout evangelical Christian woman with a long standing history of anorexia nervosa, binge/purge type, who developed religious delusions, including the conviction that God was prohibiting her from eating. The discussion emphasizes the difficulties of diagnosing and treating psychosis in devout individuals, and the interplay between anorexia, psychosis, and religion.