Scrupulosity – The Little Known OCD

Scrupulosity – Diagnosing and treatment of the Obsessive Compulsive Disorder called Scrupulosity. Obsessive-Compulsive Disorder (OCD) is an anxiety disorder that involves (a) persistent and unwanted anxiety-evoking thoughts, ideas, or images (obsessions) and (b) urges to reduce the anxiety via some other thought or behavior (compulsions). This disorder takes many forms, but those we are most familiar with include fear of contamination/germs and a need for orderliness/organization. The television show “Monk”, starring Tony Shaloub, is probably what comes to mind for many people when they think of OCD. In this show, Monk often entertains us with his idiosyncratic tics and endless need for hand wipes. Unfortunately, when dealing with OCD in real life, it is far from entertaining. Rather, it is extremely distressful and interferes frequently with a person’s daily functioning at home, at work, and in relationships. One type of OCD, which is especially difficult to live with as well as to treat, is called scrupulosity (“seeking sin where there is none”).

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Scrupulosity is a form of OCD in which obsessions relate to moral or religious fears. In a paper published in the Journal of Anxiety Disorders, Miller and Dawson (2008) estimated that as many as one million Americans may suffer from this disorder, frequently referred to as “the doubting disease.” It’s defined as obsessive doubt about moral behavior that results in compulsive rituals or checking. Much of the time, the symptoms of religious scrupulosity are centered on religious thoughts and beliefs, and manifest as fears of blasphemy or “going to Hell.” This type of scrupulosity tends to affect people who are raised in strongly religious homes and seems to be most frequently associated in the literature with the Catholic faith. Other times, the symptoms are more of a secular moral nature and focus on the moral implications of behaviors unrelated to specific culture-bound religious practices. With this second type of scrupulosity, moral scrupulosity, the person obsesses about being a “bad” person even when he or she engages in very appropriate, socially accepted behaviors. For example, a student who happens to glance at another student’s test and then condemns herself, thinking she did something bad; or a man who is holding his infant granddaughter on his lap and believes he did something inappropriate. In both cases, the individuals continued to ruminate about what they thought they did wrong (e.g., the obsession) and then regularly checked with others for reassurance that they did nothing wrong (e.g., checking compulsion).

The symptoms of moral scrupulosity are quite different from those in other types of OCD and include pathological guilt, obsession associated with moral or religious issues, over-responsibility for others, fear of offending others, etc; however, the fundamental processes that keep the disorder ‘alive’ are the same. An obsession causes distress (i.e., fear, anxiety) and a compulsion (i.e., checking or other ritual) reduces or neutralizes the obsession. It is the compulsion that actually keeps the cycle going because it does, albeit temporarily, reduce the obsession, which results in relief, making it quite challenging to treat.

In my years of practice, I have come across moral scrupulosity far more often than I have religious scrupulosity. The reason for this is unclear, other than perhaps those who are afflicted with religious scrupulosity likely seek out the service of their clergy rather than those of a psychologist.  As with any type of OCD, the preferred modes of treatment are the use of exposure and respons prevention along with pharmacology (e.g., SSRIs). With moral scrupulosity, I have found treatment to be challenging for the simple fact that it can be more difficult to artificially orchestrate a scrupulous exposure (e.g., situation in which the person thinks they have done something wrong) than it is to orchestrate a contamination or orderliness exposure. Therefore, in scrupulous situations it is important to also incorporate guided imagery into treatment. This allows the individual to experience a scrupulous exposure via visualization, yet also provides an opportunity to inhibit their response.

In 2009, the Bio Behavior Institute put out a screening test for people who suspect they may suffer from either form of scrupulosity. This tool is not intended to be diagnostic; however, if you score high on the test, you may want to consider obtaining the opinion and assistance of a professional trained in the diagnosis and treatment of scrupulosity OCD for more clarification. How to test for Scrupulosity Obsessive-Compulsive Disorder…

Scrupulosity – Obsessive-Compulsive Disorder (OCD) Diagnosis Test

Not at all                             Somewhat                             Very much

       1                   2                   3                   4                   5

  1. I often feel the need to confess minor mistakes to others.
  2. I worry that I am offending others.
  3. I have a strong sense of right or wrong.
  4. I frequently worry that God or others will punish me for things I am doing wrong.
  5. I am afraid I am not acting 100% in accordance with the law (legal, social, or moral).
  6. I always want to do the right thing and I am extremely bothered when I think I have not.
  7. I am excessively concerned about saying my religious prayers or certain phrases “perfectly” and need to repeat them if I make a mistake.
  8. I frequently think about how to be a moral person.
  9. I am excessively concerned about telling the truth.
  10. I am overly concerned about behaving ethically.
  11. I will do everything in my power to do what I think is “just” or “right” even if it is not in my best interest.
  12. I will go to every extent to return something that does not belong to me.
  13. If I am charged for an item for less than what it goes for, I will immediately tell the salesperson.
  14. I am shameful of having “immoral thoughts.”
  15. I have to tell the whole truth and nothing but the truth in all circumstances – no white lies.
  16. If I inadvertently put wrong information on a form, I will do everything in my power to correct it.
  17. Honesty is the most important virtue.
  18. If someone lies, he/she will be punished in some way.
  19. People who are not completely honest will be punished in some way, in this life or in the afterlife.
  20. I must always do the “right” thing.

Scrupulosity – Obsessive-Compulsive Disorder (OCD) Diagnosis Test Scoring Guide – Add up the responses to all the questions to earn a total score.  The higher your score the more likely it that you may be suffering from scrupulosity.

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Services offered by Dr. Fadell include individual, family and couples therapy (ages 5 through adult); cognitive therapy for weight loss and maintenance; women’s issues; and psychological testing for ADHD and learning challenges. Dr. Fadell is in private practice in Bloomfield Hills and on staff at St. Joseph Mercy Hospital. Visit www.drfadell.com for more information.

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Scrupulosity – The Little Known OCD article orginally posted in 2011.