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CLINICAL REPORTS

Religion and Guilt in OCD Patients

GAIL STEKETEE, PH.D.

Boston University

SARA QUAY, B.A. AND KERRIN WHITE, M.D.

M&ran Hospital

Abstract - The present study examined the relationships among type and severity of
obsessive-compulsive symptoms, types of religious practice and upbringing, degree of
religiosity, and guilt. Subjects were 33 OCDs and 24 patients with other anxiety disor-
ders. Findings indicated that no type of religion was more prevalent among OCD
patients than other groups. OCDs were not significantly more religious or more guilty
than other anxious subjects. Nonetheless, severity of OCD pathology was positively
correlated with both religiosity and guilt, whereas moodstate was not. Social anxiety
was associated with guilt but not with religiosity. OCDs who were more religious
more often reported religious obsessions, but not sexual or aggressive ones. Guilt was
not related to any type of obsession. As expected, greater religious devotion was relat-
ed to more guilt in OCDs, but not in other anxiety patients. The relationship between
religion, guilt, and OCD symptoms is discussed and suggestions for further research
are proposed.

As obsessive-compulsive disorder (OCD) receives increasing attention for

its high prevalence, biological bases, and responsiveness to pharmacologic and
behavioral treatments, further research is needed to explore the psychosocial
variables that may influence its development and affect treatment outcome.
Prominent features of many OCD patients include high levels of guilt, anxiety,
and depression regarding sexual and aggressive thoughts, as well as ideas of
sin and hell, which are followed by compulsive confession, prayer, and reas-
surance seeking from family, friends, and clergy (e.g., Rachman & Hodgson,
1980). The incidence of religious obsessions and/or rituals has ranged from 5%
(Dowson, 1977) to 11% (Akhtar, Wig, Varma, Pershad, & Verma, 1975) in
previous studies of adults and 13% in children and adolescents (Swedo,
Rapoport, Leonard, Lenane, & Cheslow, 1989). Sixteen of 102 (16%) consecu-
tive patients in our clinic reported religiously based OCD symptoms.

Address reprint requests to Gail Steketee, Ph.D., School of Social Work, Boston University, 264 Bay
State Rd., Boston, MA 02215, U.S.A. This research was supported in part by grant #ROl MI44190
funded by the National Institute of Mental Health. Thanks are extended to Tobey Klass, Ph.D., for
her helpful comments on an earlier draft of this paper.
359
 360 G. STEKETEE, S. QUAY AND K. WHITE

Elsarrag (1968) and others (e.g., Akhtar et al., 1975) have suggested that
obsessive-compulsive symptoms are culture-specific, as evidenced by, for
example, the absence in Northern Sudan of cancer obsessions, which are a
common Western concern, and conversely, the prevalence there of obsessions
about tuberculosis and leprosy, which are not reported in western cultures. In
Moslem countries, compulsions most frequently include cleaning because of
the important role that cleanliness plays in Moslem religious rituals (Okasha,
Kamel, & Hassan, 1968). Like culture, religion may play a role in OCD as a
medium that partly determines how, although not necessarily whether, symp-
toms are expressed.
In many normal religious believers, guilt about committing a sin can be alle-
viated through the ritual of religious confession. Not surprisingly, those with
religious obsessions and rituals often feel a compelling need to follow religious
rituals, such as prayer, confession, and church attendance, perfectly. Such reli-
gious “scrupulosity” may be a specific form of OCD. According to Greenberg,
Witztun, and Pisante (1987), this phenomenon was reported as early as the 1 lth
century for Judaism and the 16th century for Catholicism. Numerous cases of
excessive religious preoccupation among orthodox Jews have been reported
(e.g., Greenberg et al., 1987; Hoffnung, Aizenberg, Hermesh, & Munitz,
1989), although the incidence of such difficulties is unknown.
A substantial percentage of Catholic parochial students (14% to 25%)
appeared to develop excessive “scrupulosity,” especially during puberty, but in
most cases the condition was seen as transitory (Weisner & Riffel, 1960).
Nonetheless, the problem was sufficiently persistent that in the 19th century
the church distributed guidelines to assist priests in managing such overzeal-
ous parishioners (Byrne, 1989). Present day pastoral counselors are encour-
aged to refer such individuals for psychiatric help and avoid encouraging them
in their “neurotic behavior.”
Religion may be associated with OCD through the intervening variable of
guilt, defined by Klass (1987) as self-reproach and remorse for one’s behavior
as if one has violated a moral principle. Rosen (1975) has suggested that guilt
serves as a drive that motivates compulsive responses, much as does fear or
anxiety. Whether OCD is a guilt or anxiety-determined disorder, he proposed,
depends on whether the patient’s early history emphasized the evil or the fear-
ful nature of the impulses. Supporting evidence from a nonclinical sample of
college students was reported by Niler and Beck (1989): Perceived guilt pre-
dicted intrusive thoughts and impulses, whereas depression and anxiety did
not. For many patients, guilt may motivate rituals independently of religious
concepts. For example, one patient experienced obsessive guilt about causing
an auto accident by kicking a nail or stone into the roadway and checked
repeatedly to be sure such objects were removed.
The present study was designed to examine the relationships among types of
religious practice and upbringing, degree of religiosity, type and severity of
obsessive-compulsive symptoms, and guilt and depression in obsessive-com-
pulsive and other anxiety disorders. OCD subjects were hypothesized to be
more religious than other anxious patients, and religiosity was expected to be
related to OCD symptoms more than to other types of psychopathology.
 RELIGION AND GUILT IN OCD 361

Furthermore, OCD subjects who reported obsessions with religious, aggres-

sive, or sexual themes (typical sources of guilt over wrongdoing in strict reli-
gions) were expected to be more religious and more guilty than those who
obsessed about other issues. We also hypothesized that guilt would be higher
in OCD subjects than in other anxious patients and that guilt, but not mood-
state, would be positively associated with religiosity. We were also interested
in examining whether guilt would be greater in more socially anxious subjects.
Finally, because Catholicism is prevalent in the Boston area, we specifically
examined the frequency of Catholicism among OCDs in comparison to other
patients, and the relationship of Catholicism to type of obsession and to guilt.

METHOD
Subjects
Participants in this study were: (a) 33 outpatients with OCD and (b) 24 out-
patients with other anxiety disorders (6 panic disorder without agoraphobia,
10 panic disorder with agoraphobia, 7 social phobia, 1 generalized anxiety dis-
order). All diagnoses were made at a one-hour intake interview by experi-
enced clinicians using DSM III-R criteria; standardized diagnostic interviews
were not conducted. Among OCDs, 52% were male, mean age was 34.2, and
years of education was 13.8; for anxious patients, 38% were male, mean age
was 33.7, and education averaged 14.8 years.

Measures
The following information was collected for all subjects: religion of origin,
current religion, self-reported religiosity (how religious subjects considered
themselves to be at present on a scale from 0 to 4), and the Problematic
Situations Questionnaire (PSQ, Klass, 1987) scored for Total Guilt (TOT),
Interpersonal Harm Guilt (IHG), Norm Violation Guilt (NVG), and Self-Control
Failure Guilt (SCFG). No psychometric data is available for the measure of reli-
giosity. The PSQ was shown to have satisfactory internal consistency and good
stability; its validity was supported with respect to depression and self-criticism.
More extensive data were collected on the OCD subjects alone, including
measures of severity of (a) OCD symptoms as assessed by the Maudsley
Obsessional-Compulsive Inventory (MOCI, Hodgson & Rachman, 1977), and
the Compulsive Activity Checklist (CAC, Freund, Steketee, & Foa, 1987); (b)
moodstate measured by the Beck Depression Inventory (BDI, Beck, Ward,
Mendelson, Mach, & Erbaugh, 1961), and the State-Trait Anxiety Inventory
(STAI, state score, Spielberger, Gorsuch, & Lushene, 1970); and (c) social
anxiety according to the Fear of Negative Evaluation (FNE, Watson & Friend,
1969) questionnaire. Classification of obsessions according to thematic con-
tent was determined for OCD subjects using the Yale-Brown Obsessive-
Compulsive (YBOCS) Checklist (Goodman et al., 1988) completed by an
interviewer in consultation with the patient.1

lAn early version of the YBOCS Checklist was employed that did not identify subtypes of reli-
gious obsessions.
362 G. S’IEKJXEE, S. QUAY AND K. WHITE

Data Analyses
(X-square analyses were used to examine gender differences and type of
religion. T-tests were used to compare samples on other demographic vari-
ables, religiosity, and guilt, and to compare OCD subjects with and without
religious, aggressive, and sexual obsessions on religiosity and guilt.
Associations between religiosity, guilt, moodstate, social anxiety, and severity
of OCD symptoms were analyzed via Pearson correlation coefficients.

RESULTS
OCD subjects did not differ significantly from anxiety-disordered subjects
with respect to sex, age, education, or religious devotion. On the latter vari-
able, both groups scored on average in the moderate range (means were 1.8
for OCD and 1.7 for anxiety subjects). However, religiosity in OCD patients
was significantly positively correlated with measures of obsessive-compulsive
symptoms (MOCI and CAC, TS = .40, p < .04), but not with measures of other
types of pathology (BDI, STAI and FNE, TS = .06 to .16, n.s.), suggesting
some association of religiosity and OCD symptoms.
Diagnostic groups also did not differ significantly on type of religion of ori-
gin or current religion according to chi-square analyses. Among OCD subjects
64% were Catholic, 12% Protestant, 15% Jewish, and 9% professed other or
no religion. Of anxiety subjects, 50% were Catholic, 25% Protestant, and 17%
Jewish, with 8% in the none or other categories. In subsequent analyses of
religion, divisions based on type of religion other than Catholicism were not
possible due to the small sample sizes,
Data from the YBOCS Checklist regarding type of obsession was available
for 24 OCD subjects; for the remaining 9 subjects, the Checklist was complet-
ed using information from case records and consultation with the therapist.
Eleven subjects (33%) reported religious obsessions (e.g., images of the devil
raping the Virgin Mary followed by praying rituals, washing rituals following
associations of genitals and the church). Of these 11, only 2 were concerned
with careful observance of religious rites or rules (confessing sins, feeling
contrition), usually labelled “scrupulosity.” The most common religious rituals
were focused on avoidance of sexual thoughts and feelings considered unac-
ceptable according to the patient’s interpretation of religious doctrine. An
additional 4 reported nonreligious sexual obsessions (e.g., washing rituals fol-
lowing masturbation, fears of contaminating [impregnating] other women with
husband’s semen); thus, a total of 9 patients (27%) had sexual obsessions
and/or rituals. Thirteen (39%) reported aggressive ones2 (e.g., causing acci-
dents by leaving objects in the road, images of stabbing someone). Some over-
lap occurred: Both religious and sexual obsessions occurred in 6 subjects, reli-
gious and aggressive ones in 6 subjects, and 4 had both aggressive and sexual
ones. Three subjects had all three types of obsessions.

2We did not label a subject’s obsessions as aggressive unless they involved directly harming others;
hence, we omitted several obsessions subsumed under the heading “Aggressive” in the YBOCS
Checklist (e.g., fear of doing something embarrassing, doing something wrong) and included rituals
to prevent self from harming others.
 RELIGION AND GUILT IN OCD 363

TABLE 1
GUILT SCORE!.5 FOR OCD AND ANXIETY
%JBJBcrS
(STANDARD DEVIATIONS ARE IN PARENTHESES)

OCD Anxiety
n=32 n=2d
m (X) I P

Total guilt 12.38 12.62 -2s n.s.

(3.1) (3.3)

Interpersonal
Ham guilt 12.47 12.46 .Ol n.s.
(3.2) (3.7)

Nom-violation
guilt 13.47 13.22 24 n.s.
(3.2) (3.3)

Self-control
Failure guilt 11.82 12.26 .48 n.s.
(3.3) (3.4)

Those with religious obsessions were significantly more religious than

those who did not report such obsessions (means were 2.73 and 1.29 respec-
tively, t(30) = 3.9, p < .OOl). No trends regarding type of religion or religiosity
were found for those with aggressive obsessions. By contrast, there were non-
significant trends (ps < .lO) for those with religious and/or sexual obsessions
to be more often Catholic and for sexual obsessions to be positively associated
with religiosity.
With respect to guilt, contrary to our hypothesis, OCD subjects did not dif-
fer significantly from anxiety subjects in total guilt score or in any of the guilt
subscale scores on the PSQ (f-test results are given in Table 1). However,
severity of OCD symptoms was moderately and significantly positively corre-
lated with most measures of guilt (rs ranged from .40 to .46 with one excep-
tion), whereas measures of moodstate (anxiety and depression) showed little
relationship (rs were in the .2 to .3 range, see Table 2). Interestingly, social
anxiety was significantly associated with all guilt scales (rs = .44 to ~58).
The presence of sexual or aggressive obsessions was not related to level of
guilt according to t-tests: Those who reported having such obsessions did not
report more guilt than those who did not. Nor were the guilt scores for sub-
jects with religious obsessions higher than for those with nonreligious obses-
sions, although means were in the expected direction. The degree of religious
devotion was significantly positively correlated with OCD subjects’ interper-
sonal harm guilt and total guilt score (rs = .37, p < .05, see Table 3).
Interestingly, guilt and religiosity did not correlate significantly for subjects
with anxiety disorders other than OCD. Catholic OCD subjects were not sig-
nificantly more guilty than non-Catholics, according to t tests of current reli-
gion and religion of origin.
364 G. STEKFXEZ,S. QUAY AND K. WHITE

TABLE 2
PEARSON CORREW\TION BETWEEN LEVEL OF GUILT AND DEGREE OF

PATHOLOGY IN OCD SUBJECTS (SAMPLE SJZE IS GIVEN IN PAFWMESES)

MOCI CAC BDI STAI FNJZ

(2% (26) (2% (28) (2%

Total guilt .44* .46* .28 .36 .53**

Interpersonal
h guilt .46** .44* .31 .28 .58***

Norm-violation
guilt .40* .42* .22 .43* .44*

Self-conuol
failure guilt .32 .44* .18 .23 .46**

‘p <.05.**p<.Ol, ***p<,001.

DISCUSSION
Some caution is needed in interpreting the above findings. The sample sizes
are relatively small to draw firm conclusions and diagnoses were not validated
using a standard interview schedule for DSM III-R. Further, classification of
obsessions via the YBOCS Symptom Checklist was retrospective for 9 (27%)
of the OCD subjects.
Our findings suggest a relationship of religion, guilt, and OCD symptoms,
although the association does not appear to be a simple one. Contrary to our
clinical impression, we did not find OCD subjects to be more religious than
other anxiety-disordered subjects, but by the same token, our results did
indicate that subjects with religious obsessions and rituals considered them-
selves more devout than those who had other types of OCD symptoms.
Similar but less striking findings were apparent for those with sexual obses-
sions. More than the type of religious beliefs, their strength (and possibly
rigidity) seems to contribute to the development and persistence of religious
obsessions and compulsions.
Both Greenberg (1984) and Rapoport (1989) have proposed that religions
that emphasize ritual penance and purification (such as Catholicism and
Judaism) may predispose followers to religious obsessions or compulsions.
Our results did not clearly indicate that Catholicism played a prominent role in
religious OCD symptoms, although clinical impression has suggested some
association. Trends in the data might become significant with a larger sample
and more detailed information about the emphasis on religious ritual during
upbringing. Unfortunately, we had too few Jewish subjects in our sample to
investigate the association of Judaism to religiosity, guilt, and OCD. We sus-
pect that such problems may be prevalent in any group with strict religious or
moral codes, including fundamentalist Protestant sects and some eastern reli-
gious movements.
 RFLIGION AND GUILT IN OCD 365

TABLE 3
PEARSONCORRFLATIONS
BETWEXNGUILT AND
RELJoIOSKYIN OCD AND ANXIETY SUBJECTS

Religiosity

OCD Anxiety
n=32 n=%

Total guilt .31* .20

Interpersonal
Harm guilt .37* .20

Norm-violation
guilt .29+ .21

Self-control
Failure. guilt .27 .23

Contrary to our clinical impression, we did not find that OCDs differed
from other anxiety subjects (who were mostly panic-disordered) in their
degree of guilt. Nor were their scores noticeably higher than normative sam-
ples on which the PSQ measure was validated. Nonetheless, greater guilt on
the PSQ was associated with greater obsessive-compulsive symptoms (as well
as social anxiety), but not with moodstate, arguing for some specific associa-
tion of OCD and guilt.
Since we did not find guilt to be significantly related to general state anxi-
ety, it may be that these emotions operate independently and both may pro-
duce avoidance behavior. We do not have measures of the association of guilt
and panic or other anxiety symptoms and therefore cannot determine whether
the correlation of guilt and symptom severity for OCDs is specific to that dis-
order or prevalent for other anxious patients.
It is also possible that the measure of guilt employed in this study may not
have adequately tapped the type of guilt prevalent among OCD subjects. Such
guilt may be more pervasive or differently focused (e.g., responsibility for
harm) than the more normative, intra- and interpersonal guilt assessed in the
questions of the PSQ. Possible alternatives to the PSQ include the Beall
Situational Upset Scale for Shame and Guilt Proneness, which assesses guilt
about causing psychological or physical harm to others and violating moral
rules (SUS, Smith, 1972). These items might more directly tap the OCD
patient’s guilt, which often involves concern about causing physical harm to
family members and loved ones if rituals are not perfectly performed. The
Mosher Total Guilt Scale (1966, 1968) which contains subscales of Sex Guilt,
Hostility Guilt, or Morality-Conscience Guilt, may also be useful in assessing
guilt in OCDs.
366 G. STEKETEE, S. QUAY AND K. WHITE

As expected, religiosity was moderately positively associated with the

degree of guilt, particularly interpersonal harm guilt, which may most closely
reflect obsessive fears, and this was only true for subjects with OCD. A corre-
lation of .20 (p < .OOl) between religiosity and guilt in a normal sample was
reported by Demaria and Kassinove (1988). This relatively low correlation
was similar to the nonsignificant one (.20) found for anxiety subjects in the
present study. Perhaps the stronger association of religiosity and guilt is pecu-
liar to OCD. Particularly susceptible to the development of OCD symptoms
may be those who are raised by parents and religious teachers to believe that
“thinking is the same as doing,” that sexual and aggressive ideas and urges are
bad (sinful), and that such thoughts can and should be controlled. Such teach-
ings may be especially problematic for those raised in perfectionistic, as well
as strictly religious, homes.
As Klass (1989) has pointed out, most theorists regard guilt as serving a
positive function at moderate levels. However, in certain disorders, such as
OCD, depression, and post-traumatic stress disorder, guilt may become exag-
gerated to a point where it generates severe symptoms that interfere with func-
tioning. Further research establishing the pervasiveness and severity of guilt in
OCD, as well as its role in maintaining obsessive fears and compulsive rituals,
is needed before we can address the question of how best to treat very guilty
patients. Is guilt causal of some OCD symptoms or is it a characteristic feature
that derives from some underlying source? Whether guilt responds to standard
behavioral treatment via exposure and prevention of rituals is unknown and
merits further examination.

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