Scrupulosity OCD, or just Scrupulosity, is a subtype of Obsessive Compulsive Disorder (OCD) characterized by pathological guilt or personal responsibility associated with moral issues or religious themes, which can be displayed and conceptualized in several ways.
Individuals experiencing scrupulosity will experience intrusive, unwanted thoughts, images, or urges about violating their religious, moral, or ethical beliefs.
This might include a fear of offending God, committing a sin, praying incorrectly, misinterpreting religious teachings, or going to the “wrong” place of worship.
According to Santa (1999), scrupulosity is “a habitual state of mind that, because of an unreasonable fear of sin, inclines a person to judge certain thoughts or actions sinful when they are not, or that they are more gravely wrong than they really are.”
These obsessions tend to be intrusive, guilt-inducing, and distressing. For example, imagine you are sitting in church, and a blasphemous thought crosses your mind unintentionally. Most of us would feel badly, but then move on from the thought without much rumination.
People experiencing scrupulosity, however, will struggle to let it go and feel consumed by guilt for having that thought. They might spend hours performing compulsions, such as repeatedly confessing to a religious leader, to reduce their distress and resolve feelings of guilt.
Compulsions are repetitive behaviors, rituals, or thoughts that are used to neutralize negative feelings and ease anxieties.
Live Experience (Gertrude) "I feel responsible not only for myself, but also for everyone around me. If a stranger loses their keys, I feel it is my fault because I didn't perform my Christian duty by ensuring they were returned safely. I am not concerned that they will get sick and die. More that they will be inconvenienced and it will be my responsibility. I watch strangers carefully to make certain they don't drop their keys or leave papers behind. It is very difficult to go to a busy part of town when I have such a huge responsibility."
For someone who suffers from scrupulosity, these compulsions might include frequent confessing, excessive praying, or persistent reading of religious texts.
Moral Scrupulosity
Scrupulosity isn’t just limited to religion; you can have moral scrupulosity, too. While scrupulosity is often referred to as “Religious OCD,” some people will differentiate between moral/secular scrupulosity and Religious OCD to distinguish between the types of thoughts and behaviors seen within each OCD subtype.
Individuals with moral scrupulosity will experience extreme doubt regarding possible violations of morality and engage in long periods of highly distressing moral rumination.
Other symptoms of moral scrupulosity include fears around: lying (even if unintentionally); unconsciously discriminating against people; whether your ethical choices are genuinely better for the greater good; or whether you’re truly a “good” person or not.
While scrupulosity has one of the longest and richest histories of any psychological disorder, it is seldom mentioned in clinical dialogue, and few people know it exists.
Scrupulosity does not appear in many psychology and psychiatric textbooks, and it is only briefly mentioned in the Diagnostic and Statistical Manual (DSM). The prevalence of scrupulosity is not well-known, and there are no reliable estimates about how frequently patients with scrupulosity present to clinicians.
However, early clinical research suggests that anywhere from 5.0% to 33.0% of OCD patients experience scrupulosity (Miller & Hedges, 2008).
Examples of Scrupulosity Obsessions
Obsessions are preoccupied thoughts that are intrusive and distressing, and people usually try various strategies to quell them.
- “Did I say something offensive?”
- “What if I told a lie?”
- “I need to make sure I don’t say anything offensive.”
- “I must have committed a sinful act.”
- “If I don’t atone for this, I will be punished.”
- “Would everyone hate me if they knew what I did?”
- “What if I go to hell?”
- “Am I an evil person?”
- “What if I caused someone to hurt another person?”
- “Am I a good person?”
Examples of Scrupulosity Compulsions
Compulsions are repetitive behaviors, rituals, or thoughts that are used to neutralize negative feelings and ease anxieties.
- Repeatedly seeking reassurance that you have not committed an immoral act
- Frequently confessing to religious leaders
- Excessively praying
- Avoiding reading religious texts
- Or, reading religious texts obsessively
- Stopping attending services
- Constantly revisiting memories of past conversations or events in your mind to determine whether or not an immoral, unethical, or sinful behavior occurred
- Avoiding people, places, objects, or events that trigger obsessive thinking, such as religious symbols or worship services
- Repeatedly rationalizing why a past act was not immoral in context
- Doing altruistic things to “prove” to yourself that you are a good person
- Debating ethics for hours in your head
- Excessive donation or other acts of exaggerated altruism/generosity
- Trying to do “good” things to make up for the “bad” things you have done
Scrupulosity Treatment
Like most other OCD subtypes, scrupulosity is most effectively treated using Exposure and Response Prevention (ERP) therapy. ERP is a type of Cognitive-Behavioral Therapy considered the first line of psychotherapy for OCD.
ERP is a structured process where people are deliberately and gradually exposed to their OCD triggers and then taught to resist the urge to perform their compulsions.
This therapy is intended to purposely invoke more anxiety in attempts to disrupt the neural circuit between the processing and action parts of the brain and “rewire” the brain so that the intrusive thoughts and ritualistic behaviors lose their power.
By staying in a feared situation and leaning into the discomfort and uncertainty without anything terrible happening, people learn that they do not need their compulsions to cope and that their fearful thoughts are just thoughts, and nothing else.
People with Scrupulosity OCD must expose themselves to both the fear that they may be morally imperfect and also to the fear that they have inadequately addressed it.
The goal is to learn to violate the belief that uncertainty about morality is unacceptable and to improve their ability to commit to value-based behaviors despite unwanted thoughts or feelings.
Examples
For example, someone might be encouraged to think about a time they had an inappropriate reaction to scripture. Then, they would work with their ERP therapist to avoid their compulsive urges to seek out reassurance through confession or prayer. They would also learn to change their perspective on handling that idea if it comes up again.
In another example, someone might believe they said something offensive and hurt other’s feelings. Their OCD tells them they have to be certain that they learned from it and that it will never happen again. They struggle to forgive themselves because compulsively clinging to guilt means they have not forgotten what they have done.
In ERP, they might intentionally expose themselves to the person they think they offended. They would then learn to abandon any mental review of the event and seek no reassurance from the person. The goal is that they can fully engage with this individual without clinging to guilt or over-analyzing the situation.
The goal of ERP is to repeatedly expose to anxiety and expose the brain to a stimulus to disrupt the neural circuit between the processing and action parts of the brain.
By leaning into the discomfort and uncertainty and exposing themselves to the feared thoughts, people learn to improve their uncertainty tolerance and to stop relying on their compulsions to cope.
The ERP process is challenging. It takes time, effort, and practice, but people learn to cope with their thoughts without relying on ritualistic behaviors.
The compulsion to avoid anxiety is a powerful driver of OCD. Still, ERP is one of the most powerful tools available for treating OCD because it directs individuals to live with the anxiety and see that nothing bad always will happen.
Will treatment make me less religious?
Sometimes, people with scrupulosity are concerned that they will become less religious or be asked to go against their moral values during ERP. Treatment for scrupulosity will not make someone less religious or less faithful to their beliefs.
ERP is not meant to change your faith or beliefs, but rather, it is intended to focus on treating the distress brought by OCD. You can still maintain your religion or beliefs while treating your OCD with your therapist, who might come from a different religious background.
The goal of treatment is to help the people practice their religion as it was intended rather than out of fear. The purpose of therapy is to restore typical religiosity.
Sources
- Abramowitz JS, Jacoby RJ (2014) Scrupulosity: a cognitive–behavioral analysis and implications for treatment. Journal of Obsessive-Compulsive and Related Disorders, 3: 140–9.
- Miller, C. H., & Hedges, D. W. (2008). Scrupulosity disorder: An overview and introductory analysis. Journal of Anxiety Disorders, 22(6), 1042-1058.
- Hezel, D. M., & Simpson, H. B. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian journal of psychiatry, 61(Suppl 1), S85–S92. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_516_18
- Santa, T. M. (1999). Understanding scrupulosity: Helpful answers for those who experience nagging questions and doubts. Liguori.
