Running head : OCD AND SCRUPULOSITY AMONG MUSLIMS 1 Obsessive-compulsive symptoms and scrupulosity among Muslims living in the United States

Rates of scrupulosity (OC symptoms related to beliefs about sin and/or morality) tend to be higher in Muslim-majority countries, even though OCD prevalence seems to be generally consistent across many countries. American Muslims (N = 32) participants completed an online self-report battery in order to expand knowledge about obsessive-compulsive (OC) symptom presentation in American Muslims in relation to other factors, such as immigration status, religiosity, and culture. There was no correlation between religiosity and scrupulosity, although there was a significant correlation between religious compulsions and OC symptoms but not religious identity or immigration status. Of the studied variables, general distress and religious compulsions emerged as a significant predictor of OC symptoms but not religious identity or immigration status. Clinical implications and limitations are discussed. OCD AND SCRUPULOSITY AMONG MUSLIMS 4 OCD and scrupulosity among Muslims living in the United States Obsessive-compulsive disorder (OCD) is an anxiety disorder distinguished by obsessions and compulsions (American Psychiatric Association [APA], 2013). Obsessions refer to intrusive and unwanted thoughts that cause distress, and compulsions refer to frequent urges to complete repetitive behaviors, rituals, or mental tasks to reduce anxiety. This psychiatric disorder affects about 2.3% of people in the United States at some point in their lifetime and about 1.2% of people in one year (Goodman et al., 2014). Similar prevalence rates were found in Puerto Rico, Germany, New Zealand, and South Korea (Weissman et al., 1994). OCD can be a very debilitating disorder as it can interfere in daily life, in relationships with others, and can cause unwanted anxiety. While most people in the general population experience intrusive thoughts from time to time (de Silva & Rachman, 1978), patients with OCD have these experiences frequently, causing undue distress. Consider a young man who fears having blasphemous thoughts. He might be disturbed by intrusive thoughts about whether God actually exists, or whether he sinned and God wants to punish him. These thoughts make him believe he is a bad person, so he spends an exorbitant amount of time praying for forgiveness to help reduce his anxiety. However, his obsessions (the ruminations about God) and compulsions (time spent praying) prevent him from properly focusing on his job, causing him to get fired. In such a case, this young man should seek culturally and religiously sensitive treatment to help him overcome his OCD so that he can reduce his anxiety and return to work without compromising his beliefs. The above case example is consistent with scrupulous presentations of OCD. Within this context, scrupulosity refers to obsessions and compulsions related to religious fears (e.g., worrying that one’s prayers have not been accepted) or moral concerns (e.g., intrusive urges to harm a stranger; Abramowitz, Huppert, Cohen, Tolin, & Cahill, 2002). The frequency of OCD AND SCRUPULOSITY AMONG MUSLIMS 5 scrupulosity in OCD varies widely around the world, from 0-93%, implying that occurrence of scrupulosity may be strongly influenced by one’s environment (Greenberg & Huppert, 2010). According to this review of scrupulosity studies, rates tend to be higher in Muslim-majority countries, although the highest rate (93%) was found in a sample of ultra-Orthodox Jews (Greenberg & Huppert, 2010). Such a high percentage suggests that clinical measures for scrupulosity should account for cultural and religious factors, as certain behaviors may be nonpathological in different environments. This study aims to expand knowledge about the relationship between obsessive-compulsive symptom presentation, religiosity, and immigration status in American Muslims (i.e., any Muslim who resides in the United States) to help improve clinical practice. The Role of Religion in OCD A heterogeneous disorder, OCD does not take the same form in each patient; specific content of obsessions and compulsions can vary from person to person (APA, 2013) and across cultures and societies (Fontelle et al., 2004; Saleem & Mahmoud, 2009). Many previous studies have examined OCD symptoms and scrupulosity in diverse populations to determine what differences exist as a function of religion and culture, highlighting the importance of understanding OCD within its environmental context. Studies in Bahrain (Shooka, Al-Haddad, & Raees, 1998) and Cairo, Egypt, (Okasha et al., 1994), found that OCD symptoms were largely religious in content, while a study in Pakistan found OCD symptom categories inadequate to measure a unique religious construct pertaining to impurity (Saleem & Mahmoud, 2009). In Iran, Ghassemzadeh and colleagues (2002) found the most common obsessions to be doubts and indecisiveness, and the most common compulsion to be washing. According to their results, the overall patterns of OCD symptoms were more similar to patterns in Western countries, despite Iranian society being heavily influenced by religion. These results, however, may not tell the OCD AND SCRUPULOSITY AMONG MUSLIMS 6 whole story as obsessional doubts and compulsive washing may have religious undertones, and current clinical questionnaires may not be able to make a clear distinction. In Iranian culture specifically, washing and cleaning often symbolizes spiritual cleansing as well, combining both religious and physical symptoms (Ghassemzadeh et al., 2002). Religious symptoms of OCD (e.g., excessive praying) may be more likely than nonreligious symptoms to go unnoticed, as the symptoms are outwardly similar to non-pathological religious activities. Even when the symptoms are distressing enough to be noticed as abnormal, they may not be seen as worthy of attention. For example, a series of interviews with young Saudi Arabian women with OCD revealed that patients were more likely to view scrupulosity symptoms as a religious issue rather than a mental health concern amenable to treatment and ended up suffering for a long time before seeking mental health services (Al-Solaim & Loewenthal, 2011). Alternatively, common religious practices may seem pathological if examined from the perspective of someone who does not identify with that religion. For example, it is not uncommon for a Muslim to pray five times a day, and some Muslims may offer daily prayers well beyond that number. It is not common, however, for Muslims to repeat the same prayer multiple times out of anxiety. In cases like this, religious knowledge is especially important for differentiating between religious practice and pathological behaviors. Rosmarin, Pirutinsky, and Siev (2010) found that religious individuals were more accurate at identifying “normal” religious rituals from OCD (pathological) rituals compared to individuals with less religious knowledge. The preceding study is particularly relevant to mental health professionals who are likely to encounter people of varying religions, cultures, and practices. Inaccurate background knowledge can result in pathologizing and possibly stigmatizing normal behaviors and practices, or, alternatively, overlooking behaviors that function to maintain or exacerbate mental health issues. OCD AND SCRUPULOSITY AMONG MUSLIMS 7 Religiosity and Religious Symptoms A common question that arises when examining religious symptoms of OCD is: How does religiosity influence the presentation of OCD? While one may explicitly identify with a religion, how central their religion is to their identity or how important religious practices are to them, will vary. The findings regarding the relationship between religiosity and scrupulous OCD symptoms are inconsistent. Tek and Ulug (2001) surveyed 45 OCD outpatients and did not find a conclusive relationship between religiosity and any clinical OCD symptoms. Similarly, Assarian, Biqam, and Asqarnejad (2006) did not find any significant relationship between OCD and religiosity, but did find that religiosity influenced contents of obsessions and compulsions. Yorulmaz, Gencoz, and Woody (2009) found that Canadian Christian students who scored higher on religiosity were more likely to score higher on symptoms related to thoughts, but the same trend was not seen in Turkish Muslims students, where only a weak correlation was found. This may be because of differences in religiosity or because of cultural differences, as the Muslims participants were recruited from a university in Turkey, and the Christian participants were recruited from a university in Canada. The previous findings regarding the relationship between religiosity and scrupulosity symptoms vary possibly because of the different measures of religiosity used across studies. Does religiosity depend on outward religious actions or internal views of the importance and role of religion in one’s life? In a study examining the role of religiosity in OCD, Yorulmaz et al. (2009) created a religiosity scale that included open-ended and Likert-scale questions addressing degree of personal religiousness and commitment such as the impact of religious principles on one’s life, relying entirely on personal opinion instead of objective religious markers. The Penn Inventory of Scrupulosity (PIOS) also measures religiosity on a Likert scale of 1 (not at all) to 5 (very strongly), answering the question: “How strongly do you hold your religious beliefs? ” OCD AND SCRUPULOSITY AMONG MUSLIMS 8 (Abramowitz et al., 2002). This question defines religiosity in terms of personal identification with one’s religious beliefs instead of outward religious practice. When comparing populations in which outward religious acts may be influenced by varying social pressure, measuring religiosity through one’s personal identification with religion as opposed to outward religious acts can help avoid measuring social conformity as opposed to religiosity. The Role of Immigration In a globalized world, working with immigrants is i