Scrupulosity refers to a form of OCD in which questions related to morality or religious / spiritual matters become the focus of obsessive fears and compulsive and ritualistic behaviors. Some individuals with OCD find that the ambiguity of religious laws or secular morality generates overwhelming anxiety. Whereas a person without OCD might feel satisfied with a “good enough” answer from the leader of her religious congregation or from talking over a moral quandary with family and friends, a person with OCD can feel driven to attain certainty in religious adherence or moral standing. In order to allay their anxiety, they may seek constant advice, reassurance and clarification from their loved ones, acquaintances, and religious leaders. They may also evaluate their behavior according to a narrow definition of acceptability, leading to elaborate rituals and profound avoidance of everyday behaviors.
Examples
Sam grew up in a religious community, but even the most observant of his family members are perplexed by his behavior. Typically, they pray before meals, but Sam insists that prayers be said in a particular way and that each person at the table assume a position that he has identified to be obedient. If a person at the table makes a sound while the prayer is said, Sam becomes upset and will not eat until the prayer is repeated in exactly the way he specifies. Sam also prays in a ritualized way at many other points in the day, and must hold his body in a certain position while he does so. If anything interferes with his prayer, he feels overwhelmed by anxiety and will get “stuck” trying to do the prayer in exactly the right way or will abandon the activity it relates to altogether. Sam also has a variety of words that he will say to himself while performing daily tasks that he feels imbue those activities with holiness. If he is not able to think these words because of some distraction, Sam will have to repeat the activity. Sometimes the words do not produce the “right” feeling, and he will have to repeat them over and over until it feels right. These tendencies have caused conflicts with loved ones and have delayed his progress in school because he cannot complete most tasks in a reasonable amount of time.
Though Sam is in his early 20s, he has not initiated any kind of romantic relationship because of fears of transgressing religious rules about sexual thoughts and behaviors, even though his religious leader has assured him that what he is concerned about would not constitute sins. He also has limited contact with peers because they do not comply with his rituals and because they might potentially have a conversation about something Sam considers a sin.
Dana, on the other hand, grew up in a religious family but no longer adheres to any particular organized religion. Her obsessions mostly focus on secular definitions of morality and “being a good person.” To this end, she spends a great deal of time considering her behavior, both present and past. If Dana notices that she might have done something that could have been rude, she alleviates her anxiety by creating lists – both written and mental – of reasons to justify her behavior. Occasionally, Dana encounters difficulty in finding enough support for her behavior or believes that the consequences of what she did are so severe that her behavior is indefensible. In such situations, Dana feels panicked, and often goes to great lengths to apologize or to correct the perceived slight. Her attempts to apologize are so extreme that, at times, the “victims” of her behavior have asked her to stop calling and have gone out of their way to avoid contact with her. Dana feels that her behavior is embarrassing and wishes that she could stop, but she also feels compelled to pursue the relief that a person’s forgiveness grants her.
For individuals with this particular kind of OCD, life – and particularly the social part of it – presents numerous challenges. Sources of sin and offense are without limit, and the person typically finds that the range of acceptable behavior becomes increasingly narrow over time. For some, like Dana, recovery is easier because they recognize that their behavior is much more extreme than is merited and is onerous for other people. Others, like Sam, have difficulty gaining perspective on their rituals and feel that, if they were to not do them, they would damn themselves or their families for eternity.
Treatment
Exposure and Ritual Prevention (ERP) for this type of obsession involves setting up a hierarchy of feared and avoided situations and behaviors. The person then works with their therapist in order to confront matters that are morally or spiritually ambiguous, while stopping their compulsions. By doing this over time, they learn to manage scrupulosity and to thus distinguish between obsessive doubts and issues of morality and spiritual welfare.