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Scrupulosity:
Religious Obsessions and Compulsions
Carol E. Watkins, MD

What is Scrupulosity?

Religious belief, and membership in a faith community are important factors in the lives of many individuals. In addition to moral and spiritual guidance, they can provide a sense of purpose, structure and community. For a certain individuals, religious beliefs become compulsive, joyless behaviors. The individual may constantly worry that he or she might say or do something blasphemous. He may fear that he has committed sin, forgotten it and then neglected to repent for the sin. He may spend long hours searching his mind to try to ferret out evidence of un-confessed sins. He is unable to feel forgiven. Specific obsessions and compulsions vary according to the individual’s religion. An Orthodox Jew might worry that he did not perform a particular ritual correctly. He might obsess about this for hours. A Roman Catholic might go to confession several times a day. Another individual could believe that anything he does might be sinful. This individual might become so paralyzed with doubt, that he or she becomes afraid to do or say anything at all.

Scrupulosity and OCD

Religious faith and religious education are not generally the causes of Scrupulosity. Actually, Scrupulosity is a form of Obsessive-Compulsive Disorder. (OCD) OCD appears to be a biologically based disorder with severe psychological consequences. The disorder occurs in 2-3% of the population (5-7 million sufferers in the U.S.). About 10% of the first-degree relatives of affected persons also have OCD.

Obsessions are recurrent thoughts or impulses that make the person anxious (such as the fear that using a public toilet will make one sick) The obsessions persist despite efforts to control or suppress them. They feel intrusive and disturbing even though the person knows that they come from his own mind. Obsessions may include fear of harming someone, contamination or of doing something embarrassing.

Compulsions are repetitive behaviors or mental acts the person feels driven to perform, often with ritualistic rigidity, to prevent the anxiety connected with the obsessions. These may include urges to wash, count, check or repeat phrases to oneself.

OCD can occur in different forms. There are a variety of different types of obsessions and compulsions. The nature of intensity of these symptoms may vary over time. Aggressive, sexual and religious obsessions sometimes occur together in the same individual.

 

Differentiating Scrupulosity from Devout Religious Faith and Practice

Because these obsessions and compulsions are intertwined in the individual’s religious life, it may be difficult for him or her to recognize that he or she has a psychiatric condition. An individual with religious obsessions often may focus excessively on one particular concern about sin while neglecting other aspects of his or her religion. Most religions place a high priority on compassion and being a good neighbor. The scrupulous individual while focusing excessively on a few specific rules may neglect this more general dictum.

Religious leaders within the Roman Catholic and Jewish community have addressed these issues. Commentators in both of these groups have writings that label scrupulosity as a sin. One rabbi called it idolatry because the excessive devotion to a specific ritual (to the detriment of good acts toward other people) elevated the ritual to a god-like status. In his book, The Doubting Disease, JW Ciarrocchi reviews Roman Catholic pastoral writings over past centuries. He feels that some of the things that priests did to help scrupulous individuals anticipated current treatments for OCD.

 

Treatment of Scrupulosity

Like other forms of OCD, scrupulosity responds to medication and cognitive-behavioral therapy. Prior to studies in the 1980's, the usual view of OCD was that it was a relatively rare disorder with a poor prognosis. However, in addition to it being now recognized as much more common (2-3% prevalence rate), it is generally considered treatable. About 60%–80% of patients show some degree of response to treatment.

The serotonin system in the brain seems to be involved in the pathology of OCD, since the medications that have been shown to be help treat OCD increase the availability of this neurotransmitter. These medications include the serotonin re-uptake inhibitors: clomipramine, fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram.

Cognitive-Behavioral therapy—specifically ERP [Exposure and Response Prevention]—has been successfully used for the treatment of OCD. The idea behind ERP is that compulsions provide only a temporary reduction of the anxiety produced by obsessions. Furthermore, the only way to experience more permanent relief is to habituate (grow tolerant of…"get used to") the anxiety caused by the obsession--without performing the compulsion. Habituation is the key factor, and clinicians start by identifying triggers that bring on obsessional thoughts and compulsive behaviors. Then they develop a graduated hierarchy of anxiety based on the patient's report. The patient "challenges" him or herself by gradually moving up the hierarchy.  In addition to exposure, the patient is instructed to refrain from carrying out the associated rituals or at least to delay the rituals by several minutes. .

This treatment can be adapted to religious obsessions and compulsions. However, the therapist must proceed with sensitivity to the individual’s cultural and religious beliefs. If this is not done, the therapy may actually increase anxiety and resistance.

Coordination Between Psychiatrist and Clergy

It is often useful for the psychiatrist and the individual’s religious leader to work together. In some cases, with permission, the psychiatrist and the religious leader may speak directly. In many other cases, the individual in treatment can be the communication bridge. The religious leader can help the individual distinguish legitimate concerns about faith and guilt from stereotyped religious obsessions. As the person with scrupulosity begins to face his fears, he may experience a temporary increase in anxiety. The religious leader can then be a source of support and encouragement. In some cases, clergy will give the individual permission to visualize things that would usually be considered sinful thoughts if it is part of the treatment for this condition. If an individual is compulsively repeating a ritual until it is perfect, the clergy may need to give the individual special permission to perform a ritual in a less than perfect manner.

Although the psychiatrist may coordinate with clergy, the psychiatrist usually remains neutral about the individual’s particular religious beliefs. Psychotherapy and religious conversion are different things. However, within the context of psychiatric treatment, the individual is often able to gain control of his or her OCD and Scrupulosity. This can lead to freedom from excessive guilt and stereotyped religious obsessions. Ultimately, the individual is freed to experience a richer life in his or her family and faith community.


 


Obsessions may often involve thoughts which seem unacceptable to the individual, so that he or she feels ashamed. Because of this, many people keep their thoughts a secret and suffer silently. In the past decade, there have been advances in the behavioral and pharmacological treatment of Obsessive Compulsive Disorder. For helpful mental health links, please see our web page www.baltimorepsych.com/Consumer.htm   


More Links related to OCD 

  • What is OCD? A brief description from the NIMH
  • Obsessive-Compulsive Foundation This organization is by and for individuals with OCD. The site contains information on medication, psychotherapy and support for individuals with OCD. There is a chat room and a message board.
  • American Anxiety Disorders Association An organization for individuals who experience the spectrum of anxiety disorders. This is a link to a self administered test for Obsessive Compulsive Disorder.

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Copyright © 2008 Northern County Psychiatric Associates
Last modified: January 20, 2008
 
 
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