Written by Jedidiah Siev, PhD
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Scrupulosity is a type of OCD in which obsessions relate to moral or religious fears. Sometimes symptoms of scrupulosity seem uniquely religious, such as blasphemous obsessions or refusal to take communion for fear of dropping the wafer. Other times, they may resemble non-scrupulous OCD symptoms, such as fears of contamination and excessive washing rituals, but the feared consequence is religious (e.g., ritual contamination and purity). In cases of secular moral scrupulosity, an individual may obsess about the moral implications of behaviors unrelated to specific culture-bound religious practice, such as being a bad person by not recycling a sheet of paper.
Although the particular symptoms of scrupulous OCD may seem quite different from those in other forms of OCD, the fundamental processes that maintain the disorder are quite similar. As with all types of OCD, obsessions cause distress (usually anxiety) and compulsions (a.k.a. rituals) are efforts to reduce distress by neutralizing or counteracting the obsessions, potential consequences, or anxiety. A careful analysis of symptoms of scrupulosity will help identify the precise nature of the moral or religious obsessions and compulsions, and particularly how they feed each other.
Individuals with scrupulosity sometimes believe that they are “pure obsessionals,” meaning that they have obsessions without compulsions. It is important to realize that compulsions can be entirely mental, and there is increasing recognition among researchers and clinicians of the ubiquitous presence of at least covert rituals. For example, an individual with intrusive blasphemous thoughts may ritualize by mentally erasing the thoughts (e.g., perhaps even picturing erasing a whiteboard), replacing them with good thoughts (e.g., thinking “God is good.”), or engaging in mental prayers in response to the obsession.
Exposure and response prevention (ERP), selective serotonin reuptake inhibitors, and clomipramine – separately or in combination – are first-line treatments for OCD, and would be appropriate for scrupulosity, as well. A foundation of a cognitive-behavioral approach to scrupulosity would likely be ERP, perhaps with the inclusion of cognitive therapy techniques to examine unhelpful or dysfunctional thinking patterns.
Individuals with scrupulous OCD about religion often express concern about working with a therapist who does not share their religious beliefs on matters that are entangled with religion. It is important to emphasize that religion is not the cause of OCD, even scrupulosity. Rather, for individuals with OCD, obsessions tend to latch onto domains of personal or cultural importance. Moreover, the goal of treatment is not to sin or violate religion any more than the goal of treatment for someone who has contamination fears is to contract HIV. Instead, the goal of treatment is to disentangle religion from OCD and to eliminate the latter. In fact, most people with scrupulosity report that their symptoms interfere with their religious experience and their relationship with God. Although treatment may involve taking permissible risks of sin that other co-religionists take (again similar to someone with contamination fears who learns to take risks that people without OCD accept), the goal is ultimately to have a more fulfilling and unadulterated religious life, in which religion is not co-opted by OCD.
Following are additional readings about cognitive-behavioral treatment of scrupulosity:
- Ciarrocchi, J. W. (1995). The doubting disease: Help for scrupulosity and religious compulsions. Mahwah, NJ US: Paulist Press.
- Deacon, B., & Nelson, E. A. (2008). On the nature and treatment of scrupulosity. Pragmatic Case Studies in Psychotherapy, 4, 39-53.
- Huppert, J. D., & Siev, J. (2010). Treating scrupulosity in religious individuals using cognitive-behavioral therapy. Cognitive and Behavioral Practice, 17, 382-392.
- Purdon, C., & Clark, D. A. (2005). Overcoming obsessive thoughts: How to gain control of your OCD. Oakland, CA US: New Harbinger Publications.
© 2011 Massachusetts General Hospital OCD and Related Disorders Program | Reprint only with permission
Tags: Cognitive-Behavioral Treatment, compulsions, ERP, Exposure and Response Prevention, Obsessive-Compulsive Disorder, OCD, religion, rituals, Scrupulosity, Selective Serotonin Reuptake Inhibitors, SSRI