Scrupulosity: The Doubting Disease

Scrupulosity, scruples, the doubting disease, religious OCD – it has many names, but what exactly is it?

Scrupulosity is a bit elusive. Most people typically haven’t heard of it before. Even in my schooling I had never heard of the term or concept until as a trainee in private practice I had my first client who met criteria for this diagnosis. Gratefully, my supervisor at the time was well-informed and he offered me helpful training for religious OCD. Since then, I’ve discovered how much I enjoy walking with people through this particularly tricky variation of Obsessive Compulsive Disorder.

A Variety of Obsessive Compulsive Disorder (OCD)

Scrupulosity is a specific type of Obsessive Compulsive Disorder (OCD). To understand scrupulosity, it’s important to first have a grasp of how OCD operates. Put simply, OCD is characterized by obsessions and how they manifest as actions in the form of compulsions. “Obsessions” are worries that become obsessive and overly intrusive. “Compulsions” are our way of attempting to soothe our obsessions by doing something about it. As an example: when someone has an excessive worry about getting sick from contact with germs, she compulsively washes her hands or cleans her home to soothe the worry.

Characteristics of Scrupulosity

With scrupulous OCD, the primary focus of the obsessive worry is directed towards religious or moral issues. The International OCD Foundation has a fact sheet for scrupulosity that sums up how it operates in a concise way. Click here if you would like to read it.

Typically those experiencing scrupulosity are religious or consider themselves people of faith. Religious OCD doesn’t select for some religions over others. Though sects, denominations, or groups that emphasize disciplined religious practices do tend to select for a higher representation of religious OCD over other varieties of OCD. To be clear, religious communities do not create or foster OCD. However, for those individuals who may already be prone to experiencing OCD, a highly disciplined religious context can pull for some of the obsessions and compulsions to manifest in a more religious form as opposed to other forms of OCD.

Since my first brush with religious OCD as a trainee, over the years I’ve since worked with several clients meeting criteria for a diagnosis of scrupulous OCD. Even within scrupulosity I’ve seen it take many forms. However, most often there is a sense of doubt and guilt at the core of the obsessions for those clients I’ve worked with. For example:

I’m not sure if I was sincere when I gave my life to God. I wonder if I might go to hell if I don’t rededicate my life to Christ. (doubt)

I am physically attracted to my coworker. I need to repent every time I look at her in order to be clean in God’s eyes. (guilt)

I’m afraid I wasn’t kind enough to the checker at the grocery store. I need to go back to him to apologize and tell him about my faith to make it right. (doubt and guilt)

Because of the key role doubt plays in religious OCD, it’s also been referred to as “the doubting disease.”

Likewise, the concept of grace that is typically a core value of the Christian faith can become extremely difficult to grasp or receive for those experiencing religious OCD. Usually there’s a head-knowledge sense that grace is extended to all of us in our various imperfections, but there is often a sense that maybe there was some unforgivable sin they committed – perhaps unintentionally – that sets them apart from God. Sometimes the concern may be that even though there is grace, that any errors might be creating some distance between the individual and God, which can be highly disconcerting as well.

OCD, or Healthy Religious Practice?

Scrupulosity is unique from other forms of OCD because often for a person of faith and their clergy it can seem unclear whether some of these thoughts and responses to them are truly excessive, or if they might simply be a healthy part of religious practice.

Often church leadership will observe symptoms of religious OCD and see them as signs of the congregant’s dedication to their faith. Truthfully, most individuals suffering from scrupulosity are indeed highly dedicated in their faith. However, the issue comes when potentially problematic or harmful thoughts and behaviors are praised by religious leaders.

Sometimes the lines can get blurred between what is related to mental health as distinguished from spirituality (I wrote a blog post on this topic. Click here to see it). Ultimately, my perspective is that any practices that are harmful to an individual or those around them are psychologically unhealthy, even if those practices are done in the name of faith or spiritual discipline.

A Different Approach to Scrupulosity

The standard approach to OCD treatment is something called exposure and response prevention. The idea behind this approach is to help someone face her obsessive worry head-on without allowing her to engage in her typical compulsive response. In the example of the person fearing sickness from germs, the treatment might include having the individual get her hands dirty and not allowing her to wash her hands for a certain amount of time. The idea is that after an initial spike in discomfort, the discomfort will subside with time.

The problem with using this approach for scrupulosity is it involves inviting clients to intentionally engage in thoughts and behaviors that they may view as sinful or distancing them from God – which can be traumatic. Unfortunately, I’ve worked with clients who felt traumatized from such experiences with prior therapists.

Religious OCD must be handled with great care. When done well, the outcome can include a sense of freedom from guilt and doubt, and a deepened sense of closeness with God. This work requires a sensitive professional who has prior experience working with religious OCD before.

I hope this post offers some education so we can identify signs of religious OCD when we see it, and to know there is professional help available to treat it.

As a final disclaimer, I’d like to be clear that this blog post isn’t intended as professional counseling or clinical advice. If you’re in need of support, please consider speaking to a professional to be evaluated.