Some of the earliest suspected cases of obsessive-compulsive disorder (OCD) were of individuals who experienced symptoms of what is now known as scrupulosity. Some accounts were documented prior to the 1600’s. In those times, people often sought the help of their clergy for the symptoms. Some of these early accounts recorded were contributed by Ignatius of Loyola, John Bunyan, Robert Burton, Jeremy Taylor, John Moore and John Locke. Religious melancholy was the term utilized to describe some of these earliest reported symptoms of OCD and scrupulosity.
According to the International OCD Foundation, Scrupulosity is “a subtype of obsessive-compulsive disorder (OCD) involving religious or moral obsessions. Scrupulous individuals are overly concerned that something they thought or did might be a sin or other violation of religious or moral doctrine. They may worry about what their thoughts or behavior mean about who they are as a person.”
OCD is often misunderstood, and scrupulosity is no different than other subtypes in its misinterpretation by non-specialists. Clients can experience religious-based or morality-based scrupulosity symptoms. These symptoms fall into the obsessive-compulsive cycle whereby an individual experiences obsessions (unwanted, intrusive thoughts, images, or sensations) that lead to anxiety and distress. That anxiety and distress can lead to compulsions (physical behaviors or mental rituals that are an attempt to decrease the anxiety that results from the obsessions.)
The saying goes, “If you’ve met one person with OCD, you’ve met one person with OCD,” so there are a plethora of obsessions that one can experience even within this subtype. However, there are some common obsessions, including worries about offending God, fear of committing a sin, fear of dishonest thoughts, fear of going to hell, fear of being possessed, fear of disobeying God’s rules/laws, concerns about breaking rules, fear that a higher power is upset, and fear of sexual thoughts as immoral. These obsessions can be brought on by a number or triggers. Some common triggers that might lead to obsessions are images, people, places, activities, songs, words, and sayings. Additionally, many people with scrupulosity report not following any faith tradition or religion. In these cases, the fear is of transgressing one’s moral code rather than failing to adhere to one’s faith.
As you can imagine, these thoughts are distressing and can lead to anguish or attack the identity and core of an individual. One of the main strategies that OCD utilizes is to attack/latch on to things that are important to people. In the case of scrupulosity, this can be especially difficult to untangle due to the amount of doubt, shame, guilt, remorse and disgust that accompany these obsessions.
If we follow the OCD cycle, the next step after an increase in anxiety resulting from obsessions is compulsions. We define compulsions as any physical behavior or mental ritual that is an attempt to reduce anxiety. With compulsions, it is imperative to consider that they can take place in one's mind and can be unseen, especially since this is so common with scrupulosity. Because both mental compulsions and obsessions take place in an individual’s mind they can be tricky to detect and differentiate from one another. Again, the list of different compulsions that an individual might engage in an attempt to get relief from the obsessions is virtually endless. Some of the more common compulsions that we have seen include repeated prayer, making promises/or agreements with God, repeating holy/sacred images in ones head, replacing or neutralizing “bad” thoughts with “good” ones, confessing, reassurance seeking, and avoiding people, places or things that could bring on obsessions.
Some people misinterpret scrupulosity as something that is experienced by only one religion or faith, usually Christianity. While more research is needed, the data shows that scrupulosity symptoms have been experienced by individuals in a number of faith traditions, including Judaism, Islam, Christianity and Buddhism to name a few. And, even though scrupulosity symptoms are often related to religion and faith, they can also present in terms of morals and morality. Obsessions of this flavor can sound like “Am I a good person?” “Was doing that the right thing?” and “What if that wasn’t ethical or fair?” One way to think about scrupulosity is that it’s perfectionism and anxiety related to whatever determines your morals, be that religious or otherwise.
Whether or not it’s the primary presenting concern, it is estimated that up to a third of all individuals with OCD have some form of scrupulosity symptoms. People often have questions about how to distinguish between practicing their faith and engaging with scrupulosity. A common way to assess this is to ask them if individuals in their faith community would engage in the same behaviors (compulsions) or if they have ever voiced the same thoughts (obsessions). Oftentimes, OCD places strict rules on individuals, and determining if these rules differ from those of others in the same faith tradition can be helpful to determining if it is OCD or not. Another way is to examine the quantity and amount of the obsessions or compulsions. Finally, we can also assess any need for certainty and urgency, as those are often indicators of OCD.
There is hope, and people with OCD can experience relief from these symptoms and live the lives they want and deserve. Evidence-based frontline treatment practice for obsessive-compulsive disorder is cognitive behavioral therapy (CBT) and exposure and response prevention (ERP). Acceptance and commitment therapy (ACT) is another commonly used treatment modality. Finding a trained clinician that can walk alongside you during your journey can make the difference between living a life based on what-ifs and one firmly rooted in your values.
