- Receiving extra change from a cashier
- Accidentally omitting any loved ones from their prayers.
- Concerns with sacrilege or blasphemy: For example, someone might worry that they have inadvertently offended God or even accidentally worshiped the devil.
- Excess concern with right/wrong, morality: For example, someone may worry about always doing the morally right thing, in every circumstance.
- Performing a religious task or ritual in the wrong way
- Having committed a sin
- Behaving morally
- Going to hell
- A loss of impulse control Ref
Religious OCD: ‘I’m going to hell’
Scrupulosity: Where OCD Meets Religion, Faith, and Belief
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.
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’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.
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.
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 Secretand 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. ref
OCD, Guilt and Religion
Grace had grown up in a religious home. She was familiar with the above proverb. She understood it as a reminder to maintain pure thoughts to be a better person. Unfortunately, she was challenged by obsessive-compulsive disorder (OCD), and every time she read verses such as this, her anxiety and guilt would torment her. Honesty and integrity were often talked about in her home. Impure and blasphemous thoughts were against her religious beliefs. She had learned that if she were to sin, she could take steps to be forgiven. A broken heart, contrite spirit, and confession were essential. Her troubles began in middle school. She was taking a history test and inadvertently looked at her neighbor’s test. Her guilt drove her to tears. Because of her values, she had to come clean. She did, and failed her test. This seemed to be the beginning of her cascade of constant guilt caused by her thoughts. When a kid at school would announce someone had stolen his lunch money, she’d quickly look in her pockets, school bag, and desk to ensure she was not the thief. Her thoughts and fears felt real. Once, when she got an A+ on an English essay, she felt remorseful. Her mom had proofread her paper for spelling and grammar errors. She believed she had cheated. Getting rid of her guilt was more important than passing her class. Praying and confessing were a must so she could feel peace. “Somehow my honesty issues subsided while I was in high school. But before I began college my troubles reappeared. This time my thoughts morphed into something disgusting that drove me crazy,” she told me. Grace’s thoughts didn’t match her values. She couldn’t accept the thoughts and images in her mind of actually harming someone. She began to miss school and stay in her dorm all day. She’d spend hours “figuring things out.” She questioned her worthiness. The truth about thoughts is that every single human being — regardless of whether he or she suffers OCD — has intrusive, disturbing thoughts at one time or another. When non-OCD sufferers have a distressing thought, they may be surprised. They may say to themselves, “Whoa! That was a weird thought.” They acknowledge it and move on. On the other hand, when people who struggle with OCD have “random” perturbing and unpleasant thoughts, they panic. “Why in the world would I think such an awful thought? Where did that come from? What does this thought mean about me? I’m not this terrible person!” OCD sufferers begin to reassure themselves in many ways to decrease anxiety and guilt. Their thoughts are troublesome because they are incongruous with their moral character. After all, the scriptures tell us to have pure thoughts, don’t they? However, prophets and biblical writers did not have OCD in mind. OCD is a neurological and behavioral issue. It does not relate to religious beliefs, despite the symptoms. In truth, OCD often attacks whatever matters most to the person. In Grace’s case, as a devout, religious person, her OCD symptoms were related to that area of her life. She believed that thinking hideous thoughts would lead her to frightening actions. She began to question her self-worth. Depression began to surface because she couldn’t get rid of her “sins” despite her repeated repentance and confessions. Prayers, hymns, and certain words became rituals. She began to avoid situations, places, and people to avoid triggering any tormenting thoughts. Her “OCD mind” kept telling her of the daunting consequences she would face in the future if she were not able to control her thoughts. She could not bear the thought of seeing herself living in eternal damnation. The guilt Grace experienced was a biological consequence of her “OCD mind.” She had grown up learning “we must resist temptation,” but this wasn’t working for her. She had not learned that the guilt she felt was due not to sinning, but to OCD. As Grace began treatment, through cognitive-behavioral therapy that included exposure and response prevention therapy, she discovered that finding reassurance and hating her thoughts were the stumbling blocks in her progress. It took some time, but she finally understood that resisting her sinful thoughts was not the answer. She learned that it’s impossible to control one’s thoughts. She learned that some of her thinking errors were contributing to her suffering. For instance, most people who experience obsessions such as Grace’s have the belief that their thoughts equal their actions. This thinking error is called “thought-action fusion.” She believed that thinking something was just as bad as doing it. Grace had a constant need to assess her behavior and question her thoughts. She would spend hours figuring out the reason for her evil thoughts and how to undo them. She gained the experience and insight that thoughts are just that: thoughts. They come and go, and mean nothing themselves. The road to modify her thinking habits was not easy. But she knew that what she had been doing all these years hadn’t worked. She realized that OCD had gotten in the way of enjoying her life and religion. For as she thought, she was not. Ref
What is Scrupulosity?
A form 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.
What are the symptoms of scrupulosity?
Common obsessions seen in scrupulosity include excessive concerns about:
• Having committed a sin
• Behaving morally
• Going to hell
• A loss of impulse control
Besides excessive worry about religious and moral issues, scrupulosity sufferers engage in mental or behavioral compulsions.
Behavioral compulsions could include:
• Excessive trips to confession
• Repeatedly seeking reassurance from religious leaders and loved ones
• Repeated cleansing and purifying rituals
• Acts of self-sacrifice
• Avoiding situations (for example, religious services) in which they believe a religious or moral error would be especially likely or cause something bad to happen.
Mental compulsions could include:
• Excessive praying (sometimes with an emphasis on the prayer needing to be
• Repeatedly imagining sacred images or phrases
• Repeating passages from sacred scriptures in one’s head
• Making pacts with God
How can scrupulosity be distinguished from normal religious practice?
Unlike normal religious practice, scrupulous behavior usually exceeds or disregards religious law and may focus excessively on one trivial area of religious practice while other, more important areas may be completely ignored. The behavior of scrupulous individuals is typically inconsistent with that of the rest of the faith community.
How common is scrupulosity?
Unfortunately this is not yet known. Is scrupulosity more common among people of a particular faith? Scrupulosity is an equal opportunity disorder. It can affect individuals from a variety of different faith traditions. Although more research is needed to truly answer this question, there is currently no evidence to link scrupulosity to a specific religion.
Are people with scrupulosity more or less religious than others?
OCD makes it harder to practice one’s faith. However, there is no evidence that the moral or religious character of scrupulosity sufferers is any different from that of other people. Many notable religious leaders have struggled with this condition, including St. Ignatius Loyola, Martin Luther, St. Alphonsus Liguori, John Bunyan, and St. Veronica Giullani.
What causes scrupulosity?
The exact cause of scrupulosity is not known. Like other forms of OCD, scrupulosity may be the result of several factors including genetic and environmental influences.
Can scrupulosity be treated?
Scrupulosity responds to the same treatments as those used with other forms of OCD. Cognitive behavior therapy featuring a procedure called “exposure and response prevention” is the primary psychological treatment for scrupulosity. A certain kind of medicines called Selective Serotonin Reuptake Inhibitors (SSRIs) is the primary drug
treatment for OCD. Treatment for scrupulosity may also include consultation from leaders of the patient’s faith tradition.
Are other members of a person’s faith community ever involved in therapy for scrupulosity?
Yes, sometimes. It depends on the preferences and needs of the individual. There are a couple of ways in which religious leaders, family members, or friends from the individual’s faith community can be helpful. They may be asked to help clarify a religious institution’s stance on a particular issue relevant to the scrupulosity sufferer. The therapist may also ask them to learn new ways to help support the patient’s recovery process. Ref
By Author: C. Alec Pollard is a Professor of Family and Community Medicine and the Director of the Anxiety Disorders Center at the St. Louis Behavioral Medicine Institute. Copyright © 2010 International OCD Foundation (IOCDF), PO Box 961029, Boston, MA 02196, 617.973.5801 http://www.ocfoundation.org
SCRUPULOSITY: RELIGIOUS OBSESSIONS AND COMPULSIONS
The term, scrupulosity, refers to a form of obsessive-compulsive disorder (OCD) that involves religious obsessions, but it is not a separate type of OCD like hoarding disroderor excoriation (skin-picking disorder). Scrupulous individuals have an overwhelming concern that certain things they do or say violate religious or moral doctrine. They spend an inordinate amount of time each day thinking and worrying about whether they’ve committed a sin or violated moral rules. People who attend church on a regular basis, pray daily (even several times a day), and are very involved in their religious communities aren’t typically sufferers of scrupulosity. Scrupulous behavior typically exceeds or disregards actual religious law and focuses entirely on a single inconsequential area of religious practice, often completely ignoring other areas. Those suffering from religious scrupulosity usually exhibit behavior that does not align with the rest of his or her faith community.
Scrupulosity symptoms vary with the individual, but all have to with fear of sinning or breaking some sort of moral or religious rules and consequently suffering some sort of punishment. Common obsessions that occur with OCD scrupulosity include excessive preoccupations with:
- Going to Hell
- Moral behavior
- Loss of control over urges
In addition to preoccupation with religious or moral concerns, people suffering from scrupulosity perform mental or physical rituals in an attempt to make up for their perceived failings. Those who engage in only mental compulsions have the pure OCDform of scrupulosity.
Common physical compulsions include:
- Excessive visits to church for confession
- Unnecessary acts of self-sacrifice
- Repetitive purifying and cleansing behaviors (i.e. hand washing, scrubbing floors)
- Seeking constant reassurance from loved ones and pastors or priests of his or her goodness
- Avoiding religious services or other events where they believe they may commit a public sin or moral error and cause something bad to happen
Common mental compulsions include:
- Excessive prayer, often requiring that they repeat the prayer over again until they do it perfectly
- Repeating verses or passages of scripture silently in the mind
- Constantly making pacts with God
- Repetitive thinking about sacred images or pictures
Scrupulosity affects individuals from a broad variety of religious backgrounds, not just those of one particular faith. Experts suspect many highly respected religious leaders have struggled with scrupulosity, including St. Veronica Giullani, St. Ignatius Loyola, Martin Luther, St. Alphonsus Liguori, and John Bunyan. Ref
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