Scrupulosity OCD: How This Obsessive-Compulsive Disorder Affects Mental Health

Obsessive-compulsive disorder (OCD) is typically driven by intrusive thoughts leading to uncontrollable behaviors called compulsions. These thoughts and behaviors can impact an individual's daily life, functioning, and mental health. There are several subtypes of OCD that one might struggle with, including but not limited to scrupulosity OCD. Below, explore the symptoms of scrupulosity OCD, its causes, and guidance on how to get help for you or someone you know with scrupulosity OCD. 

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What is scrupulosity OCD?

Scrupulosity OCD is a subtype of OCD that affects an estimated 1.5 million people in the United States throughout a lifetime. Scrupulosity is defined by the American Psychological Association (APA) as “an over-conscientiousness regarding right and wrong, often manifesting as an obsession with moral or religious issues” that leads to compulsive behaviors. The APA also specifies that, while scrupulosity is typically referred to as OCD, it’s more frequently associated with obsessive-compulsive personality disorder (OCPD). This subtype can cause significant mental health challenges, sometimes co-occurring with disorders like depression.

Signs and symptoms of scrupulosity OCD 

Symptoms of scrupulosity can emerge at any age, but, like other forms of OCD, they typically begin in adolescence and early adulthood. Also, like different types of OCD, scrupulosity and its symptoms may overlap with other mental health disorders. For example, people with religious scrupulous OCD might have strong beliefs related to helplessness or hopelessness, guilt, and anxiety, such as those experienced by people with major depression. Individuals with ADHD may experience difficulties with impulse control, which can overlap with the compulsive behaviors in OCD. OCD behaviors are often associated with anxiety disorders like social anxiety, phobias, and panic disorder. Additionally, studies have linked OCD with schizophrenia and bipolar disorder. 

Obsessive thoughts

People with scrupulosity may have persistent, unwanted thoughts about committing sins, even minor ones. They might worry about saying or thinking blasphemous thoughts. They might be overly concerned with how others view their religious behaviors or commitment. Other typical obsessive thoughts associated with religious and moral scrupulosity include:

• Excessive focus on moral perfection and purity
• Doubting one's religious beliefs or practices 
• Intrusive thoughts about causing harm due to perceived moral wrongdoing
• Overthinking past actions or thoughts, wondering if they were sinful

Compulsive behaviors

The other primary characteristic of OCD involves compulsive behaviors resulting from obsessive thoughts. People with scrupulosity OCD might exhibit the following behaviors:

• Repeatedly engaging in religious rituals (more frequently than in a typical religious practice or religious services), such as praying or confessing, often to religious figures or authorities
• Compulsively reading from or citing passages from religious texts
• Constantly seeking reassurance from others about moral or religious issues 
• Avoiding situations, people, or places that bring anxiety or intrusive thoughts about sin
• Engaging in repetitive rituals like compulsive cleaning or washing to reduce anxiety and prevent perceived harm
• Engaging in self-punishment or acts of self-sacrifice to make up for perceived sins

Emotional symptoms 

Emotional distress typically persists throughout the cycle of obsessions and compulsive behavior. Scrupulosity is often characterized by overwhelming guilt and anxiety related to perceived moral failings. People with scrupulosity might have anxiety about being punished by a higher power for perceived sins or worry about losing their place in the afterlife. Feelings of hopelessness due to intense anxiety and guilt are also common. 

Causes and risk factors of obsessive-compulsive disorder

Research about what causes OCD is ongoing, but experts think it’s likely due to a combination of factors. Some studies suggest dysregulation in specific brain regions involved in regulating thoughts and emotions may be a cause or contributing factor. People with a family history of OCD, including scrupulosity, may be at greater risk of developing the disorder. This relationship may be genetic, but OCD behaviors can also be learned through observation or modeling from family members or others. 

In some cases, stressful life events, trauma, or significant changes can incite or exacerbate OCD symptoms in individuals who are predisposed to the condition. Exposure to adverse childhood experiences (ACEs), such as abuse, has been linked to an increased risk of OCD. Certain beliefs or personality traits, such as a tendency towards perfectionism or anxiety, may also contribute to developing scrupulosity. Additionally, people with anxiety disorders, depression, or substance use disorders may be at a higher risk for developing OCD. 

Differentiating scrupulosity as a mental health condition from genuine faith or morality

Additionally, faithful adherence to religious or moral principles often involves a shared set of beliefs and practices within a community. In contrast, scrupulosity can include rules and compulsions outside the norm or contradict the faith tradition. Scrupulosity can significantly impair functioning in all areas of life, whereas faith and morality typically contribute to a more balanced and fulfilling existence. 

Diagnosis and assessment of obsessive-compulsive disorder

OCD is typically diagnosed by a mental health professional, such as a therapist or psychiatrist. To begin, the therapist may conduct a thorough interview with the individual to understand their symptoms, family history, and how the obsessions and compulsions impact their daily life. Although there are several diagnostic tests for OCD, self-reporting tools such as the scrupulosity inventory (SI) can offer a more complete picture of symptom severity. 

They may compare their assessment to the diagnostic standards for OCD outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Although scrupulosity isn’t listed as a specific OCD subtype, the DSM-5-TR does recognize that OCD can manifest in various ways, including themes related to religious or moral obsessions. Mental health professionals use the DSM-5-TR as a guideline for diagnosis, but they can also use their clinical judgment and knowledge to understand and treat conditions like scrupulosity.

Are there diagnostic differences between scrupulosity and OCD?

Although research is ongoing, some evidence suggests there might be a distinction between scrupulosity and OCD as separate conditions. For example, while scrupulosity involves ethical and moral rumination with logically connected behaviors, OCD features more intrusive, distressing thoughts leading to often unrelated compulsions. Additionally, people with scrupulosity may have less self-awareness and insight into their condition than people with other types of OCD, stronger beliefs, and different responses to standard OCD methods. 

Easing the anxiety of scrupulosity: Treatment approaches to OCD

Mental health treatments are typically tailored to the individual's needs and symptoms. While they might vary between people, scrupulosity generally is treated with many of the same methods as those used for other types of OCD: a combination of psychotherapy and medication. There are several types of psychotherapy that professionals can use to help people with OCD, but some have been clinically proven to be more effective than others. Often, the goal of treatment is to help individuals separate their OCD from their religious and moral values, allowing them to live a life consistent with their beliefs without being overwhelmed by the intrusive thoughts and compulsions of scrupulosity. 

Cognitive behavioral therapy (CBT) 

CBT works by helping individuals understand the obsession-compulsion cycle and identify and challenge negative or distorted thoughts associated with their obsessions. CBT therapists also teach their clients how to cope with the emotional distress and anxiety that often comes with obsessive compulsions as they arise. For example, therapists might integrate mindfulness practices and relaxation techniques into CBT for OCD to help individuals manage anxiety and distress.

Exposure and response prevention (ERP)  

ERP is a specialized form of cognitive behavioral therapy (CBT) used to treat OCD. It involves gradually exposing individuals to situations that trigger their obsessions while preventing them from engaging in their usual, related compulsive behaviors. This process may help clients break the cycle of obsession and compulsion, ultimately reducing the intensity and frequency of both. 

Medication options for anxiety and obsessive-compulsive disorder (OCD) 

Selective serotonin reuptake inhibitors (SSRIs) are the primary medication treatment for OCD and are often effective in reducing the symptoms of scrupulosity. They work by changing serotonin levels in the brain, which helps regulate mood and reduce the intensity and frequency of obsessive thoughts and compulsive behaviors. While medication might be effective, research still suggests that a combination of psychotherapy and medication is often more effective than medication alone. 

The BetterHelp platform is not intended to provide any information regarding which medication or medical treatment may be appropriate for you. The content provides generalized information that is not specific to one individual. Do not take any action without consulting a qualified medical professional.

The role of spirituality in recovery 

Scrupulosity can severely impair a person’s health and well-being, and managing symptoms often involves getting a diagnosis and treatment from a mental health professional. Still, spirituality can also be a valuable tool in the healing process. With guidance from trusted counselors or religious leaders, individuals can reframe their relationship with faith and recognize it as a source of love and support as opposed to judgment or punishment. This reframing can help individuals move away from the obsessive worry and anxiety that often accompany scrupulosity. 

With a spiritual or religious practice, individuals can develop a more accepting, compassionate view of themselves and their faith, moving away from perfection and unrealistic expectations to focus on living a meaningful life. Also, scrupulosity can cause guilt and shame, hindering the healing process. Through spirituality, one may discover self-compassion and forgiveness, helping to move away from self-blame and negativity.

Supporting someone with scrupulosity OCD or anxiety 

If you know someone struggling with scrupulosity OCD, there are steps you can take to support them on the path to healing, beginning with learning about scrupulosity OCD, its symptoms, and its causes. Listen without judgment and let them know that you understand their distress and anxiety are real and challenging to cope with. Let them know you're there for them, regardless of their struggles. 

Offering reinforcement of religious obsessions or engaging in compulsive behaviors can make their OCD symptoms worse. Instead, encourage them to recognize the situations, thoughts, or behaviors that trigger the obsessions and compulsions. Suggest that they attend support groups or speak with a therapist who specializes in OCD. 

OCD can affect every area of life

Find healing in therapy

Finding mental health care for scrupulosity OCD 

Like other forms of OCD, scrupulosity is highly treatable with therapies like CBT and EPT. However, accessibility issues, mental health stigma, and affordability concerns may deter people with scrupulosity from seeking help. Virtual therapy offers a solution to many of these barriers and more. Online therapy platforms like BetterHelp allow individuals to attend sessions from home on a schedule that fits their needs. Online therapy is also often more affordable than traditional therapy without insurance. 

Research indicates that online therapy can be as effective in treating OCD as attending in-person sessions. For example, one study published in the Journal of Medical Internet Research measured therapeutic outcomes for 3552 adults with OCD participating in an internet-delivered ERP treatment model. After three weeks of live, twice-weekly video sessions followed by six weeks of once-weekly 30-minute check-ins, researchers found that “video teletherapy treatment demonstrated effectiveness in reducing obsessive-compulsive and comorbid symptoms and improved quality of life. Further, it achieved meaningful results in less than half the total therapist time compared with standard once-weekly.