Scrupulosity, also known as religious obsessive–compulsive disorder or scrupulous–compulsive disorder (SCD), is a mental disorder defined by intrusive thoughts about moral or religious ideas, pathological feelings of guilt, and compulsions which attempt to mitigate such thoughts. It is widely understood as a subtype of obsessive–compulsive disorder (OCD).
Common obsessions include fears about having blasphemous thoughts, unwittingly committing immoral actions, being condemned to hell, or improperly performing religious obligations. Compulsions often take the form of excessive prayers, obsessive study of religious doctrine, or avoidance of religious obligations and objects. Individuals with scrupulosity often exhibit paralyzing doubt about whether they fully understand their moral principles, leading to rumination. They often have difficulty acknowledging that their thoughts and behaviors are irrationally motivated and may have difficulty interpreting exaggerated language in religious contexts.
Scrupulosity is generally treated with psychotherapy; cognitive behavioral therapy (CBT) and exposure and response prevention (ERP) are both common approaches in treatment. Psychopharmacological treatments, such as selective serotonin reuptake inhibitors (SSRIs), may be prescribed to those with OCD if symptoms are severe enough, though effectiveness with scrupulosity appears to be lower. Clinicians often collaborate with appropriate clergy to help bolster patient trust in the process, fortify the patient's understanding that their thoughts are disordered, and prepare clergy to support treatment in ecclesiastical settings. Clergy also help clinicians disentangle normative religious practices from disordered ones.
Prognosis for scrupulosity is generally worse than other forms of obsessive–compulsive spectrum disorders, being more resistant to treatment overall. The mental energy cost of obsessions and compulsions can lead to increased comorbidity, especially depressive and other anxiety disorders. People with scrupulosity are at a higher risk of depression, low self-esteem, self-harm, and suicide.
Etymology
The word scrupulosity is derived from the word scruple. The latter is derived from the Latin term ('small rock, pebble'), such as the kind of small rock that one would get in their shoe while walking which later carried a sense of mental uneasiness. A later semantic shift in the jargon used by apothecaries led to scruple meaning 'one twenty-fourth of an ounce', a measure which would only be noticed on extremely sensitive scales. This sense developed in parallel in vernacular English to mean an inconsequential moral interpretation which could only bother an overly-sensitive mind.
Classification Traditionally, scrupulosity has been treated as a subtype of obsessive–compulsive disorder (OCD) and such categorization remains the majority opinion. Under a four-prong model of OCD, it is categorized as a subtype manifesting as obsessions of unacceptable thoughts which seek out reassurance-based compulsions. In a five-prong model based on factor analysis, it belongs to a category of "religious, sexual, and aggressive obsessions" with no explicit compulsion model. Certain obsessions, such as beliefs that one may not have appropriately followed religious obligations or those regarding one's damnation, may also be considered a part of the "harm to self or others" category.
Some clinicians have pushed for scrupulosity to have a distinct diagnosis from OCD since at least the early 1990s. According to this view, patients with scrupulosity exhibit similar symptoms to those of OCD, but typically have "poorer insight, higher fixity of belief, greater perceptual aberration, and more severe magical ideation". The obsessive thoughts of those with scrupulosity differ from diagnostic guidance as the obsessions are about pertinent real-life problems. Similarly, compulsions found in OCD are typically irrational and intended to minimize anxiety, whereas many compulsive behaviors associated with scrupulosity are similarly excessive but logically informed and intended to resolve the issue once and for all.
Critics of this view argue that functional evidence clearly demonstrates overwhelming similarity with OCD, even if there are some noteworthy topographical differences. Other kinds of OCD which manifest as unacceptable thoughts show nearly identical neutralization strategies and follow similar cyclical patterns. Co-occurrence with other forms of OCD, especially with obsessions about sex and violence, is also a common argument for categorizing scrupulosity as a form of OCD. Similarly, obsessions are known to shift thematically over the course of a patient's lifetime; it is not uncommon, for example, for a person to have scrupulosity obsessions in childhood, but another kind of "unacceptable thoughts" category as an adult.
Signs and symptoms Scrupulosity is a psychological disorder in which an individual experiences distressing and maladaptive obsessions regarding moral or religious issues and performs compulsive behaviors which attempt to mitigate the distress caused by such obsessions. Those with scrupulosity exhibit multiple dysfunctional lines of thought, including placing undue emphasis on the role of their thoughts, an excessive need for control, a heightened sense of responsibility, and an impaired ability to estimate threats. Though mostly associated with religion, scrupulosity has been found in irreligious people where it manifests as fears of being immoral or bad.
The disorder is marked by two primary archetypes: obsessions of wrongdoing with compulsions seeking reassurance and obsessions of punishment with compulsions of avoidance and of repentance. In most individuals, some combination of both archetypes are present. Coreligionists, including clergy, often view the behaviors that cause these obsessions or avoidances as guiltless, easily pardonable, or otherwise unimportant, but they cause significant distress in patients. The vast majority of those with scrupulosity feel that their symptoms interfere with their relationship with God.
Like other forms of OCD, scrupulosity is extremely idiosynchratic and heterogeneous, meaning that manifestations vary widely from person to person and may be derived from a variety of etiologies, or origins. For example, religious icons may be sought out by one individual with scrupulosity for comfort and avoided by another for fear of triggering religious obsessions.
Obsessions
Individuals with scrupulosity have "a habitual state of mind" in which dysfunctional moral or religious thought patterns pervade, and feelings of guilt and personal responsibility are disproportionately amplified. These religious obsessions are sometimes known as scruples. Being irrationally fearful of sinning, they believe their own licit behavior is sinful or that their sinful behavior is more transgressive than it really is. Intrusive thoughts about committing blasphemy, sexual immorality, and other immoral actions in the past or the future are commonly reported, as are thoughts that a religious duty has been performed improperly or that the individual will be divinely punished. Other common themes include that one is unwittingly committing a sin, feelings that one may lose control and become immoral, doubts about faith, fears that one's worship will not be accepted by God, and fears of going to hell. Patients often feel that they are improperly penitent or that they are uncertain if their intrusive thoughts are wanted or not. They exhibit more negative ideas about God, envisioning the deity as "punishing, fearsome, jealous, terrifying, angry, [and] vengeful", which scales with disorder severity. The manifestation of obsessions varies based on religion and cultural context. Obsessions generally fall into four categories, which often overlap:
Blasphemous intrusive thoughts (egodystonic; e.g., a Christian with intrusive thoughts of Jesus on the Cross with an erection) Concerns about orthodoxy (egosyntonic; e.g., a Catholic who cannot reconcile his intellectual thoughts about abortion with his religious conviction and repeatedly asks his priest if he is still in good standing with the Church) General intrusive thoughts viewed through a religious lens (generally egodystonic, typically resolved with religious-themed compulsions; e.g., a man who has incestuous intrusive thoughts about his sister, blames the Devil, and prays excessively) Doubts about faithfulness or whether religious obligations have been appropriately followed (e.g., a Mormon woman who worries that by wiping after using the restroom, she is masturbating and thus is failing to appropriately follow her religious code)
Ironically, these obsessions are so rigid, narrow, and excessive that they often cause the person neglect more important aspects of their faith. In an example case, a woman was so preoccupied with her fear of having blasphemous intrusive thoughts during a religious service that she avoided them altogether. Overall, patients with scrupulosity exhibit more obsessive thoughts than other patients with OCD.
Scrupulosity is associated with moral thought-action fusion, a disordered pattern of thought that equates thoughts with actions, irrespective of if the thoughts are wanted or not. For example, an intrusive thought about having illicit sexual intercourse may compel a person with scrupulosity to bring the thought to confession – sometimes repeatedly – as if they had actually committed the sexual act, even though the thought was not willingly generated by the individual and the individual never physically engaged in such an act. Religious prohibitions against certain kinds of want may promote the occurrence of thought-action fusion in people with scrupulosity, such as the Tenth Commandment which prohibits coveting and Jesus's admonishment in the Sermon on the Mount that a man who looks at a woman in lust has already committed adultery in his heart. Thought-action fusion is more common in Christian patients than patients of other religions.
Intolerance of uncertainty Intrusive thoughts, including those about religious topics, are not themselves disordered; healthy individuals will intermittently experience abrasive intrusive thoughts, acknowledge them as absurd, and discard them. Scrupulosity does not manifest in most religious people because they recognize that thoughts must either be willfully generated or indulged by a conscious mind to be sinful. The thought-action fusion experienced by those with scrupulosity makes differentiating difficult and, even when a patient recognizes that a thought may not be sinful, they are unable to convince themselves that it is not sinful.
This disparity between the ability to accept concepts based on faith or inference is known as intolerance of uncertainty. While attested in other mental disorders, it is considered most prominent in patients with OCD, particularly in the "unacceptable thoughts" subtype of which scrupulosity is usually considered a part. As a result of such intolerance, individuals with scrupulosity feel that it is both possible and necessary to ascertain with perfect certainty the solutions to their obsessions and become greatly distressed when they discover no such certainty can exist. In combination with other symptoms, this intolerance leads patients to "practice their own religion" by developing rigid and often heterodox negative beliefs about God, leading to emotional distress.
Excessive doubt