Many people mistakenly think of Obsessive Compulsive Disorder (OCD) solely as a condition in which people wash their hands excessively or check door locks repeatedly. There are actually many sub-types of OCD. In this ongoing series, Kevin Foss, MFT of the OCD Center of Los Angeles discusses Scrupulosity, in which an individual’s OCD focuses on issues of religion, morals, and ethics. Part one of a four-part series.

One of the first documented references to Obsessive Compulsive Disorder (OCD) was in a 1691 sermon by Bishop John Moore of Norwich in which he discussed men and women who were overwhelmed with unwanted thoughts, and tormented by feelings of guilt and shame over what he described as “religious melancholy.” Priests had started to notice that some churchgoers were attending confession several times a day, and repeatedly confessing to the same sins and shortcomings that they feared would result in divine judgment and eternal damnation. Their penance and absolution would provide only a fleeting glimpse of peace, and then their fears would come roaring back.

In retrospect, we now know that this obsessive religious fervor is a manifestation of OCD known as Scrupulosity. People of various religions across the world are haunted by feelings of doubt, guilt, and anxiety that torment them by attacking that which they find most dear – their faith. Scrupulosity is a form of OCD in which the sufferer’s primary anxiety is the fear of being guilty of religious, moral, or ethical failure. Those afflicted with Scrupulosity fear that their effort to live according to their spiritual values not only isn’t good enough, but is in direct violation of God.

Why Scrupulosity is Different From Other Forms of OCD

Some variations of OCD, while painful and confusing to those suffering their effects, focus on thoughts that are far removed from the individual’s values, beliefs and character. For example, the teacher with Harm OCD who fears he will somehow become a mass murderer, or the student with Gay OCD (also known as HOCD or Sexual Orientation OCD) who constantly questions her sexual orientation, can at some point recognize that the focus of their obsessions is totally at odds with who they are – with their true values and beliefs.

But this is not so for the scrupulous, as they would argue that there is nothing more central to them, indeed nothing that more clearly defines the main purpose of their life, than their spiritual beliefs and religious practices. For those suffering with Scrupulosity, the content of their thoughts hits painfully close to home. To make things worse, in many religions, challenging the doctrine or body of belief can be viewed as challenging the faith itself and an act of apostasy.

One question that repeatedly comes up when assessing clients for Scrupulosity goes something like this: “How do I know that what I am experiencing is Scrupulosity, and not an actual sin, or lack of faith, or even a demonic attack?” The answer to this question lies in the client’s intensity of focus on perfectionism. There is a significant difference between feeling convicted in your faith and pursuing your beliefs, as opposed to focusing enormous amounts of time and energy on perfectly following a few specific rules or doctrines, while turning a blind eye to others that may actually be more important.

On the Other Hand…Why Scrupulosity is the Same as Other Forms of OCD

While Scrupulosity may at first appear vastly different from the traditional presentation of OCD, those with religious, moral, and ethical obsessions experience the same Obsessive Compulsive Cycle as others with OCD – obsession, anxiety, compulsion, and relief / reinforcement.

Triggers for Scrupulosity can be any thought, image, feeling, place, person, etc., that cues an obsession. For example, seeing an attractive person at church may result in sexual thoughts, which in turn trigger an obsessive desire to “undo” that thought in an effort to be pure, holy, and clean. If the scrupulous individual upholds an exaggerated belief that lustful thoughts in and of themselves will automatically result in eternal condemnation, the cycle begins.

As in all forms of OCD, the obsessive thoughts in Scrupulosity often take the form of “What if…” questions, such as “what if I just sinned” or “what if I don’t actually believe in God”? In some cases, the thoughts may be somewhat more irrational in nature, such as “what if just by looking at that woman, I accidentally fondled her breasts”? Instead of recognizing the thought for what it is (just a thought), the sufferer responds to it as if it is a fact.

Symptoms of Scrupulosity

Those suffering with Scrupulosity hold strict standards of religious, moral, and ethical perfection. For example, if held in a black and white view, certain passages in the Bible and other religious texts may carry with them intense burdens of condemnation. In holding a strict view of these religious verses, the Scrupulosity sufferer experiences not just intense guilt, but also anxiety about the threat of eternal punishment for having violated religious precepts. Without having chosen to experience these obsessions (OCD thoughts being both intrusive and unwanted), the individual experiencing Scrupulosity feels an overwhelming urge to take whatever compulsive action offers the promise of relief.

Common Obsessions in Scrupulosity

Obsessions may include any thought or mental image that the individual experiences as evidence of religious, moral, or ethical failure, including:

Repetitive thoughts about having committed a sin

Exaggerated concern with the possibility of having committed blasphemy

Excessive fear of having offended God

Inordinate focus on religious, moral, and/or ethical perfection

Excessive fear of failing to show proper devotion to God

Repeated fears of going to hell / eternal damnation

Concern that one’s behaviors will doom a loved one to hell

Unwanted sexual thoughts about God, Jesus, or a religious figure such as a priest

Unwanted mental images such as Satan, 666, hell, sex with Christ, etc.

Excessive fear of having acted counter to one’s personal morals, values, or ethics

Common Compulsions in Scrupulosity

For the individual with Scrupulosity, compulsions can be defined as any intentional thought or behavior done in an effort to neutralize or reduce the individual’s sense of guilt, pain, and anxiety. Like all forms of OCD, compulsions in Scrupulosity can be categorized into four types:

Overt behavioral compulsions

Avoidance behaviors

Reassurance seeking behaviors

Mental compulsions

For some with Scrupulosity, their compulsion may be to repeatedly confess something they have done or thought. Some may even confess despite not actually having done or thought anything they perceive as being “unacceptable” – basically confessing “just in case”. For others, washing one’s hands or showering several times (or several hundred times!) can be a way to figuratively cleanse the soul. Likewise, avoidances of specific triggers such as places of worship, religious ceremonies, or disciplines is often a compulsive tactic employed in an effort to stave off the possibility of guilt and anxiety. Paradoxically, these efforts almost always increase the unwanted feelings. Just as with any compulsion, the momentary relief gained is enough to reinforce the obsessive thought and continue the OCD cycle.

Common compulsions may include:

Repeated and ritualized confessing (to religious figures such as priests, church elders, and/or to friends and family)

Reassurance seeking about behaviors and thoughts related to religion, morals, ethics, or values

Excessive, ritualized praying and/or reading of the bible or other religious texts

Repeating specific verses from the bible or other religious texts (either out loud or silently)

Mentally reviewing past acts and/or thoughts in an effort to prove to one’s self that one has not committed a sin or acted in a manner thy construe to be immoral or unethical or counter to one’s faith

Ritualized “undoing” behaviors to counteract perceived sins and transgressions

Excessive acts of self-sacrifice (i.e., giving away relatively large amounts of money or earthly possessions)

Avoidance of situations in which one fears the onset of obsessions related to issues of faith (i.e., church, temple, mosque, prayers, movies with devil themes, dating)

Avoidance of certain objects that one associates with immorality or sin (i.e., certain clothes, certain numbers)

Making deals with God to avoid eternal damnation (or merely to reduce current anxiety and discomfort)

Treatment of Scrupulosity

Treatment of Scrupulosity can be difficult as it requires sufferers to take a risk by challenging their fears. As with all forms of OCD, the most effective method for treating Scrupulosity is Mindfulness Based Cognitive Behavioral Therapy, with a strong emphasis on Exposure and Response Prevention (ERP). This approach to treatment focuses on three primary techniques:

Mindfulness – helping the client learn to willingly accept the existence of unwanted thoughts, without over-reacting to them with compulsive and avoidant behaviors

Cognitive Restructuring – in which the client learns to effectively and consistently challenge the accuracy and importance of their unwanted and distorted thoughts.

Behavioral Therapy – with an emphasis on Exposure and Response Prevention (ERP), a technique in which the client intentionally experiences the anxiety-producing thoughts and situations that trigger their OCD episodes, while not doing any compulsive or avoidant behaviors. A variant of ERP called imaginal exposure can also be extremely helpful in challenging Scrupulosity obsessions. ERP can be painful, as it requires the client to feel as if they are doing something sacrilegious or dangerous to their faith. But in the long-term, ERP helps the client to reduce their unwanted compulsive and avoidant responses, and allows them to live their faith freely and with more authenticity.

Scrupulosity Across Religions

It is worth noting that Scrupulosity is not partial to any one religion, but rather custom fits its message of doubt to the specific beliefs and practices of the sufferer. Furthermore, strict adherence to the tenets of various religions may at times actually inhibit the progress of treatment. The following are some examples of how Scrupulosity may manifest in some belief systems, and how treatment may be compromised due to an overly strict interpretation of religious teachings. This is by no means meant to be an exhaustive list, but rather to provide the reader with a basic understanding of how excessively strict adherence to articles of faith can complicate the experience and treatment of Scrupulosity.

Christianity

Catholicism and Protestant Christianity both share the New Testament messages of purity and adherence to various laws and doctrines that, for many, prove painful and seemingly impossible to abide by in their entirety. For example, in the Gospel According to St. Matthew, verse 5:28, Jesus states, “I tell you that anyone who looks at a woman lustfully has already committed adultery with her in his heart.” If we expand this to men and women, gay and straight, the message is that we must never have sexual thoughts for anyone but our spouse, which is all but impossible.

Judaism

Judaism’s books of law contain 613 individual commandments, and any single law can be a stumbling block for someone with Scrupulosity. Furthermore, Judaism has a strong tradition of being intellectual as well as spiritual in its practice and experience. Many consider arguing over interpretation and posing questions to be part of the process of finding the “true” way of the faith. As such, accepting ambiguity, which is a core principle of Mindfulness Based Cognitive Behavioral Therapy, may be seen as an affront to the faith itself.

Islam

Like many other religions, Islamic theology includes “Shaytan”, a devil character who serves as a “whisperer” of doubting thoughts who encourages men and women to sin. People of all faiths, including Islam, experience intrusive thoughts that make them uncomfortable, and may attempt to suppress these unwanted thoughts. But what pops into our heads is to a great extent out of our control, and attempts at thought suppression are doomed to failure. That said, asking a scrupulous Muslim to allow the words of Shaytan to dwell in their thoughts, or to intentionally approximate some of the whispers, can be construed as an assault on their faith.

Mormonism

Similar to other forms of Christianity, Mormons experience a strong sense of obligation to maintain “purity. The book of Alma, verse 12:14 notes, “Our words will condemn us, yea, all our works will condemn us . . . and our thoughts will also condemn us.” Hence, not only is a scrupulous Mormon tirelessly fighting to control their actions, but even their thoughts will “condemn” them. Indeed, our experience with treating Mormon clients has shown that thought suppression can be a significant impediment to progress. Helping a Mormon with Scrupulosity learn to allow and accept the inevitable presence of unwanted thoughts can thus be quite a challenge.

New Age Spirituality

Some believe that eschewing conventional organized religion, and adopting “New Age” practices can help forge a spiritual connection without the requirements or rituals of traditional faiths. But “alternative” spirituality presents its own challenges for those with Scrupulosity. The Secret and other New Age philosophies support “positive thinking” and the “law of attraction” as a way to literally attract wealth and create the life one desires. We have treated numerous clients who are believers of the principles espoused in these philosophies who are simply unwilling to undergo CBT. It is their belief that intentionally creating and experiencing unwanted thoughts will create the very energy by which these thoughts come true.

For those with Scrupulosity, treatment can be delicate. The therapist must create a welcoming and sensitive environment for the scrupulous person to challenge their distorted thoughts, without infringing on the perceived foundation of their religious beliefs. In short, effective therapy must challenge the importance and meaning of specific aspects of their faith for the sake of honoring and preserving their overall belief. Treatment with a psychotherapist who specializes in Mindfulness Based Cognitive Behavioral Therapy for OCD and who understands this balance is critical. Likewise, educating the therapist on the intricacies of one’s specific faith will help Scrupulosity sufferers to more appropriately challenge their OCD while also feeling confident in their beliefs. Upcoming installments in this series will explore these issues, as well as the specific techniques used in treating Scrupulosity.

To read part two of this series on Scrupulosity in OCD, click here.

To read part three of this series on Scrupulosity in OCD, click here.

•Kevin Foss, MFT, is a licensed psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. In addition to individual therapy, the center offers six weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.

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