What is Scrupulosity OCD?
Scrupulosity OCD is a common Obsessive-Compulsive Disorder (OCD) subtype in which a person experiences intrusive, unwanted thoughts, images, or urges about violating their religious, moral, or ethical beliefs. These obsessions cause the person significant distress, anxiety, and guilt, which they then try to relieve by engaging in compulsive behavior, like avoidance and excessive praying.
The term scrupulosity was first used by the Roman Catholic church to describe obsessive concern with sin and compulsive acts for the purpose of atonement. While Scrupulosity was initially identified in a religious context, obsessions and compulsions related to fear of engaging in immoral behavior are not limited to any particular belief system. Some divide Scrupulosity further into Moral/Secular Scrupulosity and Religious OCD to differentiate between types of thoughts and behaviors seen within this OCD subtype.
Here are two examples of Scrupulosity OCD:
Scenario 1: (Moral Scrupulosity) Hannah worries she may have made an offensive joke.
Hannah is talking with some friends at lunchtime. She makes a joke, but her friends do not laugh. Immediately, Hannah is plagued with intrusive thoughts:
- “They didn’t laugh. I must have said something bad.”
- “They’re never going to talk to me again. I’m a terrible person.”
- “Did I really say something offensive?”
- “I need to make sure I didn’t say something offensive.”
Hannah is very upset, anxious, and ashamed after this interaction. She finds herself revisiting the memory in her mind, trying to determine whether or not she said something offensive. She is reluctant to join in conversations with her friends at subsequent lunchtimes.
Eventually, she opts to eat by herself and makes up an excuse to tell her friends in order to avoid joining them.
Scenario 2: (Religious Scrupulosity) Eric worries he is committing blasphemy.
Eric is attending a religious service. A dialog in the religious text is being read aloud and Eric finds it funny. Then he remembers he is in his place of worship and immediately feels guilty. He thinks to himself:
- “Scripture is not to be laughed at.”
- “If I don’t atone for this, I will be punished.”
- “This means I’m an evil person.”
- “What if I go to hell?”
Eric begins to frequently confess to religious leaders that he committed a blasphemous act and he prays for forgiveness a dozen times per day. In order to avoid feeling guilty, he also starts to avoid reading religious texts and stops attending services.
Signs and Symptoms of Scrupulosity OCD
Scrupulosity OCD is like other OCD subtypes in that there is difficulty tolerating uncertainty. In the examples above, Hannah feels the need to be certain she did not offend anyone and Eric feels the need to be certain that he did not blaspheme.
This need manifests as obsessions that may be connected to a person’s moral or religious belief systems. Obsessions can take the form of thoughts, urges, and doubts like:
- “What if I told a lie?”
- “I must have committed a sinful act.”
- “What if I caused someone to hurt another person?”
- Intrusive mental images of engaging in behaviors incongruent with one’s belief system, e.g. tearing apart a holy text.
While these obsessions might start out as thoughts connected to the person’s belief system, the corresponding compulsive behavior usually goes far beyond the “rules” of that system. For example, compulsions can include:
- Repeatedly seeking reassurance that one has not committed an immoral act.
- Excessive prayer, which can be overt or can be a mental ritual.
- Revisiting memories of past events and trying to determine whether or not immoral, unethical, or sinful behavior occurred.
- Avoiding people, places, objects, or events that trigger obsessive thinking, such as religious symbols, worship services, or entertainment depicting immoral behavior.
What Causes Scrupulosity OCD?
OCD is considered a neuropsychiatric disorder caused by a combination of genetic and environmental factors. Sometimes it may be the result of a medical condition such as a brain injury or, in the case of children, after a streptococcal infection (known as Pediatric Autoimmune Neuropsychiatric Disorders, or PANS). OCD may also arise with no clear prompting event.
Although the exact cause of someone’s OCD cannot be determined, we do know that OCD causes people to think the worst thoughts about the things closest to them. With Scrupulosity OCD, for example, deeply religious or moral people can develop intense, irrational doubts about the beliefs they hold dear.
The types of unwanted thoughts people with Scrupulosity OCD experience can vary from person to person. What ties them all together is the subsequent anxiety and the need to perform compulsive behavior as a means of short term relief. Unfortunately, these compulsions are counterproductive and lead to a worsening cycle of OCD symptoms.
What are the Treatment Options for Scrupulosity OCD?
The first-line treatment for Scrupulosity is the same as other types of OCD – Exposure and Response Prevention (ERP) therapy. ERP is a structured process that exposes people with OCD to their triggers and then teaches them to resist the urge to perform their compulsions. Over time, ERP therapy can help people reduce their obsessions and compulsions, and take back control of their lives.
For people with Scrupulosity OCD, ERP therapy might include exposure to a trigger that is connected to the patient’s urge to seek reassurance. For instance, take Eric (the character from the first example, who felt guilty about finding scripture funny). One of his compulsions was to repeatedly, excessively go to confession to seek reassurance from his priest that he hadn’t blasphemed and was not going to go to hell. An ERP exercise might involve Eric thinking about a time he had an inappropriate reaction to scripture. His therapist would then help him avoid his compulsive urge to seek out reassurance through confession. Eventually, his obsessions and compulsive behavior would improve as he learns to stop relying on compulsions to relieve his anxiety in the short term.
Sometimes people with Scrupulosity OCD are concerned about being asked to actually sin or go against their moral values during ERP. This is contrary to one of the goals of ERP, which is to help people with Scrupulosity OCD be able to engage in activities that are important. A trained ERP therapist wants you to be able to live within your values, not lead a life dictated by Scrupulosity OCD.
The ERP process is challenging and requires dedication from both the person with Scrupulosity OCD and the ERP therapist. Luckily, symptoms can decrease within 10 weeks – which is a brief period of time compared to how long someone with Scrupulosity has probably lived with their symptoms.
ERP is best facilitated by a licensed therapist with specialized training in treating OCD prior to someone with Scrupulosity OCD engaging in their own self-management. ERP can be used in conjunction with certain types of medications prescribed by a psychiatrist.
NOCD therapists are trained ERP specialists who can work with you to reduce your OCD symptoms with just a few weeks of live one-on-one video therapy. You’ll also be welcomed into our supportive peer community, with 24/7 access to personalized self-management tools built by people who have struggled with OCD and successfully recovered using ERP. Schedule a call with our team if you’d like to get started.