Religious observance and obsessive compulsive washing among Iranian women

Author’s Accepted Manuscript Religious observance and obsessive compulsive washing among iranian women Somayeh Mahintorabi, Mairwen K. Jones, Lynne M. Harris, Alireza Zahiroddin www.elsevier.com/locate/jocrd

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S2211-3649(15)30018-X http://dx.doi.org/10.1016/j.jocrd.2015.10.001 JOCRD226

To appear in: Journal of Obsessive-Compulsive and Related Disorders Received date: 21 June 2015 Revised date: 29 September 2015 Accepted date: 1 October 2015 Cite this article as: Somayeh Mahintorabi, Mairwen K. Jones, Lynne M. Harris and Alireza Zahiroddin, Religious observance and obsessive compulsive washing among iranian women, Journal of Obsessive-Compulsive and Related Disorders, http://dx.doi.org/10.1016/j.jocrd.2015.10.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Religious Observance and Obsessive Compulsive Washing Among Iranian Women

Somayeh Mahintorabia, Mairwen K. Jonesa *, Lynne M. Harrisb, Alireza Zahiroddinc

a

Discipline of Behavioural and Social Sciences in Health, Faculty of Health Sciences, The University of Sydney;

b

School of Psychological Sciences, Australian College of Applied Psychology;

c

Behavioural Sciences Research Centre of Shahid Beheshti University of Medical Sciences.

Running Head: RELIGION AND OCD WASHING

*Corresponding author at the Faculty of Health Sciences, Cumberland Campus, East Street, Lidcombe, NSW 2141, University of Sydney, Australia. Tel: +61-(02) 9351 9571, Fax: +61-(02) 9351 9601. Email address: [email protected]

Abstract This study examined relationships between religiosity, scrupulosity, cognitive beliefs and Obsessive-Compulsive Disorder (OCD) among High Religious (HR) and Low Religious (LR) Muslim women with OCD washing subtype (OCD-W) who presented for treatment in Tehran. Four

groups of women were recruited for the study: HR Muslim women with OCD washing subtype (n=33); HR Muslim women without OCD (n=45); LR Muslim women with OCD-W (n=31); LR Muslim women without OCD (n=30). The OCD-W group had higher scores than the nonOCD group on measures of religiosity, scrupulosity and beliefs. The HR group had higher scores on scrupulosity and beliefs than the LR group. Compared to LR Muslim women with OCD, HR Muslim women were first diagnosed with OCD symptoms at a later age, their OCD symptoms were of maximum intensity at a later age, first sought help for OCD at a later age, were older at the time of their last visit to a health professional, were less likely to have been previously treated for OCD and scored higher on self-report measures of OCD symptomatology at the time of assessment. These findings have implications for models of OCD scrupulosity and for early diagnosis and treatment of OCD for highly religious Iranian Muslim women.

Keywords: Obsessive Compulsive Disorder; Scrupulosity; Religion; Islam; Women.

Introduction Obsessive Compulsive Disorder (OCD) is characterised by the presence of persistent and intrusive obsessions, which may result in the performance of repetitive behaviours known as compulsions (American Psychiatric Association, 2013). OCD is associated with significant impairment for individuals across many areas of life, such as work, school, social activities and family settings (Bobes et al., 2001; Fontenelle et al., 2010; Subramaniam, Abdin, Vaingankar, & Chong, 2012). Although OCD prevalence is approximately equal across different countries (Karno, Golding, Sorenson, & Burnam, 1988; Kolada, Bland, & Newman, 1994; Mohammadi et al., 2004; Weissman et al., 1994), variation has been found in the frequency and theme of the obsessions experienced by people in different cultures (Ghassemzadeh, Khamseh, & Ebrahimkhani, 2005). While contamination obsessions and washing compulsions are among the most common OCD symptoms (de Silva, 2003), religious symptoms (e.g., fear of impurity, repeating prayers) have been found to be more common among Iranian (67%; Ghassemzadeh et al., 2005; 62%; Ghassemzadeh et al., 2002), Israeli (50%; Greenberg, 1984) and Saudi Arabian samples (50%; Mahgoub & Abdel-Hafeiz, 1991), compared to a Spanish sample with OCD (7.5%; Labad et al., 2008) and a sample with OCD from the USA (21%; Mataix-Cols, Rauch, Manzo, Jenike, & Baer, 1999). Related to this, Rachman (1997) proposed that the beliefs and practices of a particular religion may influence the expression of an individual’s OCD symptoms. While studies conducted in Australia suggest that people with OCD wash because they feel contaminated by dirt and germs and seek to reduce the risk of disease or illness (e.g., Jones & Menzies, 1997; Jones & Menzies, 1998), samples from Iran, Egypt, Saudi Arabia and Israel have reported that their OCD washing rituals are driven by beliefs about purity (Greenberg & Shefler, 2002; Okasha, Saad, Khalil, El Dawla, & Yehia, 1994). Notably, purity is associated with the cultural practices of religions such as Islam and Judaism (e.g., AlSolaim & Loewenthal, 2011; Ghassemzadeh et al., 2005; Greenberg & Shefler, 2002; Shooka, al-Haddad, & Raees, 1998). Specifically, fear of impurity and the performance of washing and cleansing religious rituals related to impurity have been observed in both Muslim samples with OCD (Ghassemzadeh et al., 2005; Ghassemzadeh et al., 2002), and Jewish samples with OCD (De Bilbao & Giannakopoulos, 2005; Greenberg & Witztum, 1994). Both Islam and Judaism include cleansing rituals among their religious practices (Greenberg & Shefler, 2002; Okasha, et al.,

1994). Additionally, OCD washing-related symptomatology associated with religiosity has also been found in Christian samples (Abramowitz et al., 2004). Scrupulosity is an obsessional theme that has a close relationship with religiosity and morality (Yaryura-Tobias & Neziroglu, 1997; Yorulmaz, Karanci, & Tekok-Kilic, 2002) and is common among those with OCD (Abramowitz et al, 2002). Higher levels of religiosity have been found to be associated with scrupulosity, regardless of religious affiliation (Gonsalvez, Hains & Stoyles, 2010). People with scrupulosity may perform compulsions such as repeatedly seeking reassurance from religious leaders, repeatedly engaging in cleansing and purifying rituals, excessive praying, or repeating passages from sacred texts (Greenberg & Huppert, 2010; Sharma, Kumar, & Sharma, 2006). Research investigating scrupulosity and religiosity in OCD is important given that people with scrupulosity respond poorly to treatment compared to people with OCD without scrupulosity (Alonso et al., 2001; Ferrao et al., 2006). Additionally, Abramowitz and Jacoby’s (2014) cognitive– behavioral model of scrupulosity proposes that strong adherence to religious beliefs and principals maintains scrupulosity by increasing the likelihood that an individual will misinterpret unwanted intrusive thoughts as personally significant and sinful. It has also been suggested that those with scrupulosity may understand their OCD symptoms to be a part of their usual religious practice, and therefore not seek professional help to change their thoughts and behaviours (Huppert & Siev, 2010). Previous research has revealed that the most common first source of assistance about OC symptoms in scrupulous people are religious authorities like clergy, Rabbis, Imams and faith based healers (Huppert & Siev, 2010; Wills & DePaulo, 1991). Greenberg and Shefler (2002) reported that participants with OCD preferred to receive psychotherapy for their non-religious symptoms but preferred to talk to their Rabbi about their religious symptoms. Therefore, understanding the relationship between OCD symptomatology and religious beliefs and practices may have important implications for treatment (Akuchekian, Jamshidian, Maracy, Almasi, & Davarpanah Jazi, 2011). Al-Solaim and Loewenthal (2011) recruited a sample of Muslim females with OCD (n=15) from central Saudi Arabia in order to explore the role of religion in the manifestation of OCD symptoms. Using semi-structured interviews the researchers found that 14 (93%) of the women reported that religious OCD symptoms caused them the most suffering or distress. The majority also reported praying was the main behaviour

they used to decrease OCD-related anxiety. While it is not possible to say that religion had a causal role in the development of OCD, it did appear to influence how the OCD symptoms were manifested in this small sample (Al-Solaim & Loewenthal, 2011). Ghassemzadeh et al. (2005) recruited a sample of 135 Iranian Shia Muslims diagnosed with OCD and found that religious symptoms, such as fear of impurity, were significantly more common in females (77%) compared to males (47%). However, like other studies, Ghassemzadeh et al. did not employ a control group of Iranians with OCD who were not highly religious to examine the extent to which these findings are specific to religion rather than ethnicity. Thus, there is evidence that religiosity (Greenberg & Shefler, 2002) and/or religious affiliation (Abramowitz et al., 2004; Ghassemzadeh et al., 2005) is associated with OCD symptom presentation. However, some researchers have not found a relationship between religiosity and OCD. For example, Tek and Ulug (2001) found no relationship between religiosity and features of OCD among 45 Turkish outpatients with OCD. Similarly, Raphael et al. (1996) did not find a significant association between religion and OCD symptoms among 49 British patients with OCD. It should be noted that some of the research discussed above employed small samples, and this may account for inconsistent findings. Additionally, the lack of a low religious control group in many studies (Al-Solaim & Loewenthal, 2011; Ghassemzadeh et al., 2005), means that the specificity of findings to religious affiliation rather than broader cultural factors also limits the conclusions that can be drawn from previous work. This study aimed to address these limitations by recruiting a large sample of female Muslims with and without OCD-Washing (OCD-W) who varied in religiosity. Obtaining a better understanding of the nature of OCD-W within a religious society may improve early access to effective treatment, as well as help to direct treatment plans for HR Muslim patients with OCD. Consistent with previous findings it was predicted that there would be a significant effect of both Religiosity and OCD-W status on a measure of scrupulosity. The study also explored the relationship between OCD-W status and religiosity and beliefs regarding, Perfectionism/Certainty, Importance/Control of thoughts and Responsibility/Threat estimation subscales of the Obsessive Beliefs Questionnaire (OBQ-44; Obsessive Compulsive Cognitions Working Group [OCCWG], 2005). The current study is the first investigation of cognitive variables in women with and without OCD-W with high and low religiosity in Iran.

Method Participants A total of 139 Iranian Muslim females aged 18 to 64 years (mean age=37.7 years; SD=11.1) were recruited for either the OCD-W group (n=64) or the non-OCD control group (Non-OCD; n=75). Participants in the OCD-W were recruited from Tehran University counselling centre and four private psychiatric clinics in Tehran. All participants in the OCD-W group were females diagnosed by psychiatrists and psychologists as meeting criteria for OCD with predominant washing concerns. Participants without OCD were invited to take part in the study through advertisements at medical and psychological centres in Tehran. All participants were further divided into High Religious (HR) (n=78) and Low Religious (LR) (n=61) groups based on their response to a question from the Duke Religion Index (Koenig, Parkerson Jr, & Meador, 1997). Those who answered “definitely true of me” or “tends to be true” to the item “My religious beliefs are what really lie behind my whole approach to life” were allocated to the HR group, and those who chose “definitely not true” or “tends not to be true” to the same item on the DRI were allocated to the LR group. This is similar to the procedure used by Inozu, Clark, and Karanci (2012) to define their high religious and low religious groups. Materials Background Demographic Questionnaire included questions about age, marital status, educational background, age of OCD onset, content of OCD symptoms, OCD symptom severity, as well as questions pertinent to level of religiosity, such as the number of prayers per day, the locations chosen for daily prayer, the type of religious rituals engaged in and the number of days fasting in a year. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen, Mazure, et al., 1989; Goodman, Price, Rasmussen, & Mazure, 1989). The Y-BOCS is a clinician administrated scale comprising 10 items (Goodman et al., 1989 a, b). This scale measures symptom severity and provides five rating dimensions for obsessions and compulsions: 1) time spent or occupied with obsession or compulsion; 2)

intrusion with functioning or relationships; 3) extent of distress; 4) resistance, and 5) control (success in resistance). The Y-BOCS items are rated on a four-point scale from (0) “no symptoms” to (4) “extreme symptoms”, and total scores on the Y-BOCS range from 0 to 40. The Persian translation of the Y-BOCS has excellent reliability for the symptom checklist (Cronbach’s α=0.97; split-half reliability=0.93) and the severity scale (Cronbach’s α=0.95; split-half reliability=0.89; Rajezi Esfahani, Motaghipour, Kamkari, Zahiredin, & Janbozorgi, 2012). The Padua Inventory- Washington State University Revision (PI-WSUR; Burns et al., 1996) is a self-report measure comprising of 39 items which assess obsessions and compulsions. Items are rated on a 5-point scale according to the level of disturbance caused by the thought or behaviour (0) “not at all” to (4) “very much”. The PI-WSUR’s items measure five content areas pertinent to OCD. These areas are contamination obsessions and washing compulsions (COWC); dressing/grooming compulsions (DRGRC); checking compulsions (CHKC); obsessional thoughts about harm to self/others (OTAHSO) and obsessional impulses to harm self/others (OITHSO). Scores on the PI-WSUR range from 0 to 156. Scores on the contamination obsession and washing compulsion subscale range from 0 to 40 (10 Items). The Persian translation of the PI-WSUR has excellent reliability (Cronbach’s α=0.92; Spearman split test alpha=0.95; test- retest r= 0.77; Shams, Kaviani, Esmaili, Ebrahimkhani, & Amin, 2011), consistent with reliability in the present sample (Cronbach’s α=0.95). The Duke Religion Index (DRI; Koenig, Parkerson, & Meador, 1997) is a five-item scale that assesses three dimensions of religiosity: (1) Organizational Religiosity, using a single item concerned with attendance at religious services; (2) Non-organizational Religiosity, with one item concerned with prayer or religious study; and (3) Intrinsic Religiosity with three items concerned with spirituality. Participants respond to the Organizational Religiosity and Non-organizational Religiosity items on a six-point scale from (1) “never” to (6) “several times a week”. The Intrinsic Religiosity subscale items are rated on a five-point frequency scale from (1) “definitely not true” to (5) “definitely true”. The DRI total score is the some of the ratings for the five items and ranges from 5 to 27. The reliability of the English language DRI is good (Cronbach’s α=0.90; Storch, Roberti, Heidgerken, et al., 2004), as is the reliability of the Persian translation of the DRI (Cronbach’s α=0.89; Saffari, Zeidi, Pakpour, & Koenig, 2013). In the present sample reliability of the translated DRI was excellent (Cronbach’s α=0.93). The Santa Clara Strength of Religious Faith Questionnaire– Short Form (SCSF; Storch, Roberti, Bravata, & Storch, 2004) consists of five items and measures the strength of faith and the amount of contribution of religious beliefs to an individual’s life (e.g., “My religious faith

is extremely important to me”). Responses are based on a four-point Likert scale from (1) “strongly disagree” to (4) “strongly agree” with total score ranging from 5 to 20. The SCSF correlates highly with the original instrument from which it is derived (r=0.95), which has excellent reliability (Storch, Roberti, Bravata, et al., 2004). The Persian translation of the SCSF is also reliable (Cronbach’s α= 0.88; Pakpour, Saffari, & Zeidi 2014). In the present sample reliability of the SCSF was excellent (Cronbach’s α=0.99).

The Religious Fundamentalism Scale–Revised (RFS-R; Altemeyer & Hunsberger, 2004) comprises 12 items that assess fundamentalist religious attitudes and beliefs. Items are rated on a 9-point Likert scale, ranging from (−4) “very strongly disagree” to (+4) “very strongly agree” with a range from -48 to +48. Half of the items are reverse scored. The RFS-R was designed to be used with different religious faiths, so item content is comprehensive to all religious groups. The reliability of the RFS-R is excellent (Cronbach’s α=0.91) for the revised version (Altemeyer & Hunsberger, 2004). The RFS-R was translated to Farsi by a registered translation agency in Australia and Iran and translations were confirmed by the author, and approved by three university professors in clinical psychology in Australia and Iran and the reliability of the translated RFS-R was excellent (Cronbach’s α=0.90). The Penn Inventory of Scrupulosity (PIOS; Abramowitz et al., 2002) is a self-report measure with 19 items that assesses beliefs and behaviours indicative of scrupulosity (Abramowitz et al., 2002). The PIOS has two subscales concerned with Fear of God (7 items) and Fear of Sin (12 items). Items are scored on a 5-point scale ranging from (0) “never” to (4) “constantly” with total scores ranging from 0 to 76. The PIOS has adequate psychometric properties in nonclinical samples (Abramowitz et al., 2002). The Persian translation of the PIOS has good to excellent reliability: Fear of God (Cronbach’s α=0.90); Fear of Sin, (Cronbach’s α=0.88); and PIOS total (Cronbach’s α=0.97; Kaviani, Eskandari, & Ghavam, 2015). In the present sample the reliability was also good to excellent: Fear of God (Cronbach’s α=0.94); Fear of Sin, (Cronbach’s α=0.82); and PIOS total (Cronbach’s α=0.93). Obsessive Beliefs Questionnaire (OBQ-44; OCCWG, 2005). The OBQ-44 is a self report measure where participants indicate their general level of agreement with each of 44 statements using a rating scale from (1) “disagree very much” to (7) “agree very much”. Total scores on the OBQ-44 range from 44 to 132, and the OBQ-44 has three subscales: Inflated Responsibility/Threat Estimation (OBQ-44 Threat); Perfectionism and Tolerance of Uncertainty (OBQ-44 Perfect); Importance/Control of Thoughts (OBQ-44 Thought). The correlations between

the Persian OBQ-44 and the OCI-R (r=0.57) and MOCI (r=0.50) are statistically significant (Shams, Karmaghadiri, Esmaeli Torkanbori, & Ebrahimkhani (2004). In the present sample reliability of the translated OBQ-44 was excellent (Cronbach’s α=0.97). Procedure This study was approved by the University of Sydney Human Research Ethics Committee and by the Iranian institutions where the study was conducted. All participants received a Participant Information Statement and signed an Informed Consent Form at the beginning of the study. The study was conducted in four clinics in Tehran. OCD Washing Subtype Group (OCD-W). Clinicians provided females with OCD-W information about the study and those who chose to participate were then contacted to arrange an individual appointment prior to, or at the beginning of, their OCD treatment. At the time of the appointment participants were first screened by a psychologist registered in Iran (the first author) to ensure that they reported spending at least one hour per day on washing behaviours using the clinician administered Y-BOCS. Participants then completed the PI-WSUR, DRI, the OBQ-44, the PIOS, the SCSF, the RFS-R and finally answered the questions on the Background Demographic Questionnaire. The data was collected in a single session that took a maximum of 90 minutes. Non-OCD Control Group. Participants who responded to advertisements about the study made contact by phone or email to arrange an individual appointment. With the exception of the Y-BOCS and the interview questions that related to OCD (age of onset, severity of symptoms, family history of OCD), the same procedure was utilised for the non-OCD group. The data was collected in a single session that took a maximum of 60 minutes.

Study design and data analysis A 2 X 2 factorial design was used. The independent variables were OCD-W status (present; absent) and religiosity (high; low). For all statistical tests a Bonferroni adjustment was applied to the criterion for significance to account for multiple comparisons. For t-tests, effect sizes were expressed in terms of Cohen’s d (d), with 0.2 indicating a small effect, 0.5 a medium effect, and 0.8 a large effect. For analysis of variance (ANOVA) effect sizes were expressed as partial eta squared , with .01 indicating a small effect, .06 a medium effect, and .14 a large effect (Cohen, 1988). Results Participant Characteristics Table 1 presents the demographic characteristics of the sample along with the scores of the four groups on the measures of OCD symptomatology and religiosity used to validate allocation to groups. The significance criterion for analyses presented in Table 1 was set at p=.006 (.05/9) to account for multiple comparisons. There were no significant differences between groups in age or education (p’s>.006) (see Table 1). With regard to Religiosity, analysis of variance confirmed that there was a significant main effect of Religiosity on the DRI score, F(1,135)=1002.05, p<.001, h2p=.88, where those in the HR group had significantly higher scores on the DRI than those in the LR group (see Table 1). However, neither the main effect of OCD-W status nor the interaction between OCD-W and Religiosity were significant (p’s>.005; see Table 1). This confirms that the HR and LR groups varied in Religiosity. [TABLE 1 ABOUT HERE] With regard to OCD-W status, all participants in both OCD-W groups reported spending at least one hour per day on washing behaviours, and the mean Y-BOCS scores for both OCD-W groups (Mean Y-BOCS total for OCD-W HR=33.79, SD=3.67; Mean Y-BOCS total for OCD-W LR=30.42, SD=3.54) were above the accepted cut-off for clinical OCD of 16 using the Y-BOCS (eg Fisher & Wells, 2005). Similarly, the mean total PI-WSUR total score for those in both the HR and LR OCD-W groups was higher than that reported for a sample with

clinical OCD by Burns et al. (1996) (M=54.93; SD=16.72) and the mean PI-WSUR contamination obsession/washing compulsion subscale scores for these groups were well above those reported by Burns et al. (1996) for their clinical OCD sample (M=13.87; SD=7.96), while the scores for the OCD-W groups on the other PI-WSUR subscales were similar to those reported by Burns et al. (1996). In addition, the mean total PI-WSUR scores for those in the LR and HR Non-OCD groups were lower than the normative sample reported by Burns et al. (1996) (M=21.78; SD=16.33) and scores on the PI-WSUR contamination obsession/washing compulsion subscale were similar to those from the normative sample reported by Burns et al. (1996) (M=6.54; SD=5.53). The scores for the Non-OCD groups on the other PI-WSUR subscales were similar to or less than those reported by Burns et al. (1996). This is consistent with the clinician diagnosis of OCD-W for those in the OCD-W group, and with the allocation of participants to the Non-OCD group. It is clear from Table 1 that, in addition to the expected significant main effect of OCD-W on the PI-WSUR total score, F(1,135)=2482.39, p<.001, h2p=.95, and all of the PI-WSUR subscales (p’s<.001), where the average scores of those in the OCD-W groups were higher than those in the Non-OCD groups, there were also significant main effects of Religiosity on PI-WSUR total score, F(1,135)=33.38, p<.001, h2p=.20, and on the PI-WSUR subscales COWC, DRGRC and OTAHSO (p’s<.001), where those in the HR groups had higher scores than those in the LR groups (see Table 1). There were no significant interactions between the factors OCD-W and Religiosity on PI-WSUR total score or any of the PI-WSUR subscales (p’s<.001; see Table 1). Religious practices, Religiosity and Beliefs Table 2 presents the mean scores for the four groups on measures of religious observance, religiosity and beliefs. The significance criterion for analyses presented in Table 2 was set at p=.004 (.05/12) to account for multiple comparisons. From Table 2 there was no main effect of OCD status on the mean frequency of daily prayer, the mean time in minutes spent reading the Quran or Hadith on the most recent occasion of reading, mean number of days spent fasting each year, RFS-R, or SCSRFQ (p’s>.004, see Table 2). As expected, there were main effects of Religiosity on each of these variables (mean frequency of daily prayer, F(1,135)=719.27, p<.001,

h2p=.84 the mean

time in minutes spent reading the Quran or Hadith on the most recent occasion of reading, F(1,135)=40.69, p<.001, h2p=.23,

mean number of days spent fasting each year, F(1,135)=217.64, p<.001, h2p=.62, RFS-R, F(1,135)=1073.48, p<.001, h2p=.89, SCSRFQ F(1,135)=1399.51, p<.001, h2p=.91 (see Table 2). In all cases those in the HR group had higher scores than those in the LR group. There was a significant interaction between OCD status and Religiosity for Mean frequency of daily prayer, F(1,135)=11.03, p=.001, h2p=.08, where means suggest that the difference between the reported frequency of daily prayers for those in the HR and LR groups was smaller for those with OCDW than for the Non-OCD group. The interaction between OCD status and Religiosity was not significant for mean time in minutes spent reading the Quran or Hadith on the most recent occasion of reading, mean number of days spent fasting each year, RFS-R, or SCSRFQ (p’s>.004, see Table 2). [TABLE 2 ABOUT HERE] For measures of scrupulosity, there was a significant main effect of OCD status on PIOS total, F(1,135)=10.02, p=.002, h2p=.07, PIOS Fear of God, F(1,135)=18.15, p<.001, h2p=.12, and PIOS Fear of Sin, F(1,135)=22.67, p<.001, h2p=.14, where in each case the OCD-W group had higher scores than the Non-OCD group (see Table 2). The main effect of religiosity was also significant for PIOS total score, F(1,135)=114.23, p<.001, h2p=.46, PIOS Fear of God, F(1,135)=171.15, p<.001, h2p=.56, and PIOS Fear of Sin, F(1,135)=288.24, p<.001, h2p=.68, where in all cases, the HR group had higher scores than the LR group. The interaction between OCD-W status and Religiosity was significant for PIOS Fear of Sin, F(1,135)=23.80, p<.001, h2p=.15 but not for PIOS total score (p=.007) or PIOS Fear of God (p=.01; see Table 2), where means suggest that the difference between the PIOS Fear of Sin for those in the HR and LR groups was larger for those with OCD-W than for the Non-OCD group. With regard to the OBQ-44, the main effect of OCD status was significant for the total score, F(1,135)=362.36, p<.001, h2p=.73, and each of the subscales Responsibility/Threat estimation, F(1,135)=56.85, p<.001, h2p=.30, Perfectionism/Certainty, F(1,135)=218.26, p<.001, h2p=.62, and Importance/Control of thoughts, F(1,135)=168.02, p<.001, h2p=.55. In all cases, the OCD-W group had higher scores than the non OCD group. The main effect of religiosity was also significant for OBQ-44 total score, F(1,135)=99.41, p<.001, h2p=.42, and each of the subscales Responsibility/Threat estimation, F(1,135)=55.92, p<.001, h2p=.29, Perfectionism/Certainty, F(1,135)=9.80, p=.002, h2p=.07, and

Importance/Control of thoughts, F(1,135)=48.43, p<.001, h2p=.26. In all cases, the HR group had higher scores than the LR group. The interaction between OCD-W status and Religiosity was significant for OBQ-44 total score, F(1,135)=30.63, p<.001, h2p=.19, and Importance/Control of thoughts, F(1,135)=34.21, p<.001, h2p=.20, but not for Responsibility/Threat estimation (p=.007) or Perfectionism/Certainty (p=.12; see Table 2). The pattern of means indicates that the difference between OBQ-44 total and Importance/Control of thoughts for HR OCD-W and LR OCD-W was smaller than the difference between OBQ-44 total and Importance/Control of thoughts for HR Non-OCD and LR Non-OCD. OCD Related Experiences and Symptom Presentation To further explore differences between the experiences of OCD-W associated with Religiosity, analyses were conducted comparing HR and LR OCD-W women (see Table 3). For these analyses the significance criterion was set at p=.005 (.05/10) to account for multiple comparisons. There were significant differences between HR OCD-W and LR OCD-W women in the age at which they were first diagnosed with OCD, t (62)=3.35, p=.001, d=0.85, the age that OCD washing symptoms reached maximum intensity, t (62)=4.39, p=.000, d=1.12, the age at which they first sought help for OCD, t (62)=4.21, p < .001, d=1.07, the age when they last saw a health professional for OCD, t (62)=3.25, p=.002, d=0.83, and the current severity of their symptoms, t (62)=4.18, p=.000, d=1.06. For all of these measures, the HR group had higher scores than the LR group (see Table 3). There was a significant association between Religiosity and receipt of treatment previously, χ2 (1, n=64)=9.06, p= .003, where the HR OCD-W group were less likely to report previous treatment (see Table 3). There was no significant difference between the HR OCD-W and LR OCD-W groups in the time they first reported experiencing OCD or the severity of the first OCD washing symptoms (p’s > .005). There was also no significant association between level of religiosity and family history of OCD or the type of treatment previously received (see Table 3). [TABLE 3 ABOUT HERE] Discussion

The first prediction was supported since there was a significant effect of both Religiosity and OCD-W status on PIOS total score, PIOS Fear of God and PIOS Fear of Sin indicating that both high religiosity and OCD-W were associated with higher scrupulosity. For PIOS Fear of Sin there was also a significant interaction between Religiosity and OCD-W status, where those in the HR OCD-W group had higher scores on PIOS Fear of Sin than all other groups. The main effect of religiosity demonstrated here is consistent with the findings of other samples with monotheistic religious beliefs (Abramowitz, Huppert, et al., 2002; Olatunji et al., 2007). For example, Abramowitz et al. (2002) found that devout Catholic, Protestant and Jewish college students had higher scores on the PIOS subscales compared with less devout students, and the current findings indicate that the same patterns occur among Muslim women. The interaction between religiosity and OCD-W for PIOS Fear of Sin is consistent with the predictions of the cognitive–behavioral model of scrupulosity conceptualised by Abramowitz and Jacoby (2014), in which a strong adherence to religious beliefs and principals is understood to maintain scrupulosity by increasing the likelihood that an individual will misinterpret unwanted intrusive thoughts as personally significant and sinful. Our findings have implications for the treatment of scrupulosity among highly religious women with OCD-W. Abramowitz and Jacoby discuss strategies that may be beneficial in the treatment of scrupulosity, including employing psychological interventions commonly applied in the treatment of OCD, such as exposure and response prevention, cognitive therapy and psychoeducation that have been modified according to the maladaptive beliefs and behavioural responses identified in their cognitive-behavioral model of scrupulosity. We suggest that further research investigating the effectiveness of these strategies in highly religious people with OCD scrupulosity is warranted. The study also explored the relationship between OCD-W status and religiosity and beliefs regarding, Perfectionism/Certainty, Importance/Control of thoughts and Responsibility/Threat estimation subscales of the Obsessive Beliefs Questionnaire (OBQ-44; Obsessive Compulsive Cognitions Working Group [OCCWG], 2005). HR Muslim women with OCD-W had higher scores only on the Importance/Control of thought subscale of the OBQ-44 compared to the three other groups. These findings are consistent with previous research employing Catholic (Sica et al., 2002) and Protestant samples (Abramowitz et al., 2004), in which highly religious participants with OCD had higher scores on importance and control of thoughts compared to other groups.

Our findings also revealed that HR females with OCD-W were significantly older than the LR OCD-W group when they were initially diagnosed with OCD. This may be because the HR OCD-W women considered their OCD symptoms as normal religious rituals for a long period of time before they sought professional help. The HR OCD-W women also experienced greater current OCD severity compared to the LR OCD-W women. This may be because they started seeking professional help later, leading to a later diagnosis. The HR OCD-W Muslim women who participated in this study did not seek professional help following the onset of their OCD symptoms for an average of 12.48 years, which was approximately twice as long as the LR OCD-W Muslim women (6.16 years). This may account for the higher symptom severity observed in the HR OCD-W participants in our study. Other studies with similar findings have been conducted in Iran by Ghassemzadeh et al. (2005; 2002) who reported 7.24 years (Ghassemzadeh et al., 2005) and 8.65 years (Ghassemzadeh et al., 2002) delay before participants with OCD asked for professional help for their OCD symptoms. It is worthwhile to mention that participants in those studies included both females and males with OCD; however, the researchers found no significant difference in help-seeking behaviour between the sexes. Research findings have also identified that people who have OCD with religious symptoms prefer to ask for help first from a spiritual source rather than a mental health practitioner (Al-Solaim & Loewenthal, 2011; Greenberg & Shefler, 2002). Al-Solaim and Loewenthal (2011) reported that all of their Muslim OCD participants first asked for help from faith-based healers rather than MHPs. Participants asked for professional help when they acknowledged that the suggestions they had received from faith based healers benefited them only temporarily, and when the symptoms started to worsen (Al-Solaim & Loewenthal, 2011). This may also explain why the HR OCD-W Muslim women in our study took longer to seek professional help. Additionally, there may be a number of other reasons why HR women with OCD-W took longer to seek professional advice from health practitioners. It is possible that female HR Muslim participants may not recognise their regimented, meticulous and repeated cleansing rituals or excessive prayer as symptoms of OCD, but rather perceive these as a normal part of religious practice, that exemplifies their commitment to God (Al-Solaim & Loewenthal, 2011). Further, there are many washing rituals in Islam that need to be performed more frequently by females than

males. For example, both sexes perform ritualistic baths after sexual intercourse, but females also perform ritualistic baths after menstruation and childbirth (Siddiqui, 2008). The delay may also have occurred because religious practices acted as coping mechanisms to decrease anxiety, so that HR women may have endured their OCD symptoms for longer and sought help later or experienced comfort through prayer (Al-Solaim & Loewenthal, 2011; Perez, 2008). Similarly, if religion had a positive impact on religious people’s lives in general, they may not have wanted to detach themselves from the religious beliefs and rituals and may not have wanted to associate their religion with their OCD symptoms. In addition, religious participants may have thought that going beyond the minimum standard of religious requirements might abate their propensity for sin and fear of God’s vengeance and/or prove their spiritual devotion thus bringing them closer to God (Steketee et al., 1991). Alternatively, since in Iran there is no insurance coverage for visiting a psychologist or a psychiatrist, HR women with OCD-W may have first turned to non-professional sources for help since this was available to them and free of charge. Arguably, those who were LR may not have sought this potential avenue of help and this may explain the difference between the two groups in time to seek professional help for their OCD, particularly if the advice given by religious leaders did not include recommendations that they should seek professional help. Further research is needed to clarify these possible explanations. Similarly, Imams, with authority, knowledge and expertise of the laws and rules of Islam who are the main source for HR Muslims to gain assurance and information about beliefs and rituals in Islam, may not recognise the concerns of those with OCD as scrupulosity. Imams, faith based healers, or clergy members may also transfer the fear of God, fear of sin and guilt to those who may not be sure about performing religious rituals (3; Hepworth, Simonds, & Marsh, 2010) as having a fear of God is a cherished attitude in Muslims’ worship and one of the elements of Islamic doctrine (Inozu, Clark, & Karanci, 2012). Religious clergies’ responses increased fear of sin and the carrying out of compulsive rituals in Christian parishioners (Deacon et al., 2013). As such, it is possible that religious Imams or clergy members may also be giving advice that may inadvertently exacerbate OCD symptoms or delay treatment seeking. The main advice reportedly given by religious advisors to address symptoms among Arab Muslim females was to read verses from the Quran (Al-Solaim & Loewenthal, 2011).

While the findings from the present study are important, several limitations of this research need to be noted. Only females were included in this study since some researchers have noted gender differences in Muslim religious practice (Siddiqui, 2008). Additionally, Al-Solaim and Loewenthal (2011) in Saudi Arabia and Bjorck and Maslim (2011) in the USA, also employed exclusively female samples, so limiting our sample to females only allowed us to compare our findings with those from other studies. However, restricting the sample to females limits the generalisability of the findings. This study also employed a limited number of questions related to help seeking behaviour. Given these two limitations, future research could employ both female and male participants and use qualitative methodologies, such as in-depth interviews about help seeking among HR Muslims living with OCD-W. Further, participants were recruited only from Tehran, and therefore the sample is not representative of all Iranians, nor of Islamic cultures outside of Iran. Finally, it is acknowledged that the study is cross-sectional, and cannot determine causal relationships between variables. As such it is not possible to consider whether, for example, degree of religiosity resulted in an increase in OCD washing symptoms and religious themes in the symptoms experienced, or the reverse, or whether a third variable, such as a cognitive process, contributed to both. This study is the first to examine the relationships between religiosity, scrupulosity, beliefs, OCD-related experiences and symptom presentation among HR and LR Iranian Muslim women with OCD-W. The findings support the cognitive–behavioral model of scrupulosity conceptualised by Abramowitz and Jacoby (2014) and have implications for the treatment of scrupulosity among highly religious Muslim women with OCD-W. Finally, we propose that examining the beliefs, reactions and experiences of Muslim faith-based healers or Imams in regard to religious help seekers with OCD-W may also be beneficial.

Acknowledgements This study was funded by a University of Sydney International Scholarship granted to Somayeh Mahintorabi. We would like to thank Sepideh Rajezi, Sima Nourbakhsh and Mona Malekian for their help in participant recruitment.

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OCD-W (n=64) HR (n=33)

(n=75) LR (n=31)

HR (n=45)

LR (n=30)

ME OCD 2 F (p) h p

ME Rel 2 F (p) h p

ns

Int OCD Rel 2 p

F (p) h

.83 (.36) .006

ns

2.67 (.11) .02

ns

.26 (.61) .002

ns

.03 (.86) <.001

ns

1002 (<.001) .88

Mean age in years (SD)

40.06 (12.3)

35.19 (10.8)

37.22 (11.8)

38.60 (8.9)

.02 (.88) <.001

Mean years of education (SD)

13.39 (3.7)

13.58 (2.9)

14.29 (3.5)

14.67 (2.3)

3.22 (.08) .02

Mean DRI (SD)

23.67 (2.42)

10.90 (2.84)

23.98 (2.41)

9.60 (2.29)

1.34 (.25) .01

Mean PI-WSUR Total (SD)

67.82 (6.66)

59.77 (3.32)

17.80 (5.85)

14.83 (5.55)

2482.39 (<.001) .95

Mean COWC (SD)

33.18 (3.13)

30.29 (2.45)

7.56 (2.29)

7.00 (1.70)

3383 (<.001) .96

Mean DRGRC (SD)

7.88 (1.43)

6.65 (1.98)

2.22 (1.65)

1.50 (1.20)

387.78 (<.001) .74

* *

*

*

3.55 (.06) .03

ns ns

ns

33.38 (<.001) .20

*

7.10 (.009) .05

ns

16.80 (<.001) .11

*

7.72 (.006) .05

ns

12.71 (.001) .74

*

.87 (.35) .006

ns

Mean CHKC (SD)

16.55 (3.38)

14.84 (2.46)

4.76 (2.99)

4.17 (3.05)

476 (<.001) .78

*

4.97 (.03) .04

Mean OTAHSO (SD)

7.94 (2.49)

5.77 (1.67)

2.49 (1.79)

1.63 (1.54)

213 (<.001) .61

*

21.13 (<.001) .14

Mean OITHSO (SD)

2.27 (1.74)

2.23 (1.80)

.78 (1.36)

.53 (1.07)

37.55 (<.001) .22

*

.31 (.58) .002

ns

1.18 (.28) .009 *

ns

ns

3.97 (.05) .03

ns

.14 (.71) .001

ns

OCD-W=Obsessive-Compulsive Disorder Washing Subtype; Non-OCD=No Obsessive-Compulsive Disorder, HR=High Religious, LR=Low Religious; DRI=Duke Religion Index; PI-WSUR Total=Padua Inventory: Washington State University Revision Total score; COWC=Padua Inventory: Washington State University Revision Contamination Obsessions and Washing Compulsions, DRGRC=Padua Inventory: Washington State University Revision Dressing/Grooming Compulsions, CHKC =Padua Inventory: Washington State University Revision Checking Obsession/Compulsion, OTAHSO=Padua Inventory: Washington State University Revision Obsessional Thoughts about Harm to Self/Others, Padua Inventory: Washington State University Revision OITHSO=Obsessional Impulses to Harm Self/Others; ME OCD: Main Effect of OCD-W; ME Rel: Main Effect of Religiosity; Int OCD Rel= Interaction of OCD-W and Religiosity; * p < .005

Table 2. Religious practices, Religiosity and Beliefs of Muslim women by level of OCD and level of Religiosity Non-OCD

OCD-W (n=64) HR (n=33)

(n=75) LR (n=31)

HR (n=45)

LR (n=30)

ME OCD 2 F (p) h p

ME Rel 2 F (p) h p

ns

Mean frequency daily prayer (SD)

5.06 (.43)

1.03 (1.82)

5.22 (.88)

.03 (.18)

5.74 (.02) .04

Mean time reading Quran or Hadith in minutes (SD)

25.3 (15.56)

11.61 (24.10)

30.67 (17.57)

5.5 (11.25)

.02 (.90) <.001

Mean days fasting / year (SD)

31.3 (9.95)

4.84 (9.44)

35.11 (11.06)

6.93 (12.39)

2.54 (.11) .02

Mean RFS-R (SD)

34.91 (9.97)

-37.55 (9.81)

31.00 (9.67)

-33.30 (18.31)

.007 (.94) <.001

Mean SCSRFQ (SD)

17.97 (2.13)

8.26 (1.03)

18.36 (1.68)

7.67 (1.16)

.14 (.71) .001

Mean PIOS Total (SD)

40.55 (14.93)

12.74 (12.88)

28.33 (11.34)

11.83 (8.02)

10.02 (.002) .07

Mean PIOS Fear of God (SD)

13.94 (.44)

4.74 (.36)

9.93 (5.37)

3.73 (3.25)

18.15 (<.001) .12

Mean PIOS Fear of Sin (SD)

26.61 (11.14)

8.00 (.43)

18.40 (7.41)

8.10 (5.52)

22.67 (<.001) .14

Total OBQ-44

222.21 (19.21)

205.61 (11.03)

171.69 (25.18)

113.67 (26.69)

362.36 (<.001) .73

99.41 (<.001) .42

OBQ-44 Threat

67.64 (13.69)

56.19 (13.76)

56.04 (13.94)

31.47 (14.72)

56.85 (<.001) .30

*

55.92 (<.001) .29

Int OCD Rel 2 p

F (p) h

719.27 (<.001) .84

ns

40.69 (<.001) .23

ns

ns *

*

3.55 (.06) .03

ns

.21 (.64) .002

ns

1073.48 (<.001) .89

*

3.82 (.05) .03

ns

1399.51 (<.001) .91

*

3.21 (.08) .02

ns

*

*

7.44 (.007) .05

*

6.49 (.01) .05

*

23.80 (<.001) .15

*

*

30.63 (<.001) .19

*

*

7.44 (.007) .05

114.23 (<.001) .46 *

171.15 (<.001) .56

*

288.24 (<.001) .68 *

11.03 (.001) .08

*

217.64 (<.001) .62 ns

*

ns

ns

ns

*

OBQ-44 Perfect

85.48 (11.59)

82.45 (12.50)

60.16 (10.32)

51.20 (10.32)

218.26 (<001) .62

OBQ-44 Thought

69.09 (11.23)

66.97 (10.69)

55.49 (11.71)

31.00 (10.53)

168.02 (<.001) .55

*

9.80 (.002) .07

*

48.43 (<.001) .26

2.39 (.12) .02 *

ns

34.21 (<.001) .20

OCD-W=Obsessive-Compulsive Disorder Washing Subtype; Non-OCD=No Obsessive-Compulsive Disorder, HR=High Religious, LR=Low Religious; RFS-R=Religious Fundamentalism Scale-Revised, SCSRFQ=Santa Clara Strength of Religious Faith Questionnaire; PIOS=Penn Inventory of Scrupulosity; OBQ-44=Obsessive Beliefs Questionnaire; OBQ-44 Threat=OBQ-44 subscale Inflated Responsibility and Threat estimation; OBQ-44 Perfect=OBQ-44 Perfectionism and Tolerance for Uncertainty; OBQ-44 Thought=OBQ-44 Importance/Control of Thoughts; ME OCD: Main Effect of OCD-W; ME Rel: Main Effect of Religiosity; Int OCD Rel= Interaction of OCD-W and Religiosity; * p < .005;

*

RELIGION AND OCD WASHING

No

Yes

Mean severity of first OCD symptoms (SD)

Mean age when last saw health professional for OCD (SD)

Mean age when first sought help for OCD (SD)

Mean age OCD-W maximum intensity (SD)

Mean age when first diagnosed with OCD (SD)

Mean age when first experienced OCD (SD)

11 (33.3)

7 (21.2)

26 (78.8)

84.55 (9.71)

48.18 (10.14)

38.61 (11.84)

37.48 (13.56)

32.52 (10.54)

25.00 (8.56)

HR OCD-W (n=33) 21.18 (8.14)

9 (29.0)

22 (71.0)

2 (6.5)

29 (93.5)

78.06 (9.09)

41.94 (8.33)

30.32 (8.06)

25.19 (9.25)

22.84 (6.50)

19.03 (5.19)

LR OCD-W (n=31) 17.19 (3.61)

2.88 (.09)

4.18 (<.001) 1.06*

2.68 (.009) .68

3.25 (.002) .83*

4.21 (<.001) 1.07*

4.39 (<.001) 1.12*

3.35 (.001) .85*

2.51 (.01) .64

29

Yes 22 (66.7) 7 (31.8)

Table 3. OCD symptomatology Characteristics f Muslim women with OCD-W by Religiosity

No 5 (45.5) 15 (68.2)

Previously treated for OCD, n(%)

Type of treatment previously received, n (%)

0.59 (.44)

ns

9.06 (.003)*

ns

ns

ns

t (p) d or χ2 (p)

Mean current severity of OCD (SD)

Psychotherapy 6 (54.5)

OCD family history, n (%)

Medication OCD-W=Obsessive-Compulsive Disorder Washing Subtype; HR=High Religious, LR=Low Religious. * p < 0.005

Highlights; We examined relationships between religiosity, scrupulosity, cognitive beliefs and Obsessive-Compulsive Disorder among women in Iran. We found that high religiosity and OCD Washing were associated with higher scrupulosity Religiosity had an impact on the age at which OCD washing was first diagnosed. The findings have implications for models of OCD scrupulosity and for early diagnosis and treatment of OCD for highly religious Iranian Muslim women.