Scrupulosity: Where OCD and faith collide

By Traci Badalucco

“My name is Emily and I have scrupulosity.”

It sounds like a session of an Alcoholics Anonymous meeting. Instead, it was Emily’s first public declaration at a recent scrupulosity forum in Chicago.

She couldn’t escape her obsessive thoughts about her Christian faith and disrespectful thoughts about Jesus that would invade her mind randomly and change instantaneously while she prayed, she said.

These obsessive thoughts led to rituals, such as apologizing repeatedly, to help bring down her anxiety, a cascade of behaviors linked to scrupulosity.

“I’m like no, I don’t want to feel that way, so I’ll say sorry for it,” Emily said. “Well then, as soon as I say sorry, I commit to that ritual, and it’s like flood gates open and all these other thoughts come.”

With this condition, Emily questioned last summer whether she’d be able to go to college and live an independent, adult life.

“I remember feeling trapped, stuck, hopeless, and forever slaved to my OCD,” Emily said.

Emily compared her scrupulosity to a tumbleweed.

“The more you engage in rituals, the bigger and more tangled it gets.”

Emily made it to college with the help of behavioral therapy.  She is one of millions of Americans with Obsessive Compulsive Disorder.

Scrupulosity is a form of OCD and involves obsessive thoughts about moral character and leads to self-identified rituals that consume hours of time.

The word scrupulosity means “seeking sin where there is none,” said Jonathan Abramowitz, professor and associate chairman of the department of psychology at the University of North Carolina, Chapel Hill, and people living with the disorder have intrusive thoughts that counteract their moral identity.

Experts say scrupulosity isn’t widely recognized for two reasons: It’s commonly mistaken for exceptional faith in religious communities, and religious leaders aren’t trained in mental health, making it difficult for them to recognize the symptoms.

“To some extent, it is socially reinforced,” said Abramowitz. “It can be seen in some circles as a virtue.”

Dr. Karen Cassiday explains treatment options for scrupulosity patients at a recent Beyond OCD forum in Chicago. (Traci Badalucco/Medill)

Clergy will often prescribe prayer or fasting to people with obsessive thoughts, which then backfires and becomes a ritual, said Karen Cassiday, director of the Anxiety and Agoraphobia Treatment Center in Chicago and Deerfield and a member of Beyond OCD’s Scientific Advisory Board.  She also treats Emily.

“It could even just be a bad word or a bad idea, something seen as being sacrilegious,” Abramowitz said.

People with scrupulosity misinterpret these thoughts, so they perform rituals to get rid of them and reduce anxiety.

Abramowitz said one example is people in the Islamic religion, who place an emphasis on cleanliness, obsessing about cleaning rituals.

“It can be a never-ending battle where the person is just fighting these intrusive thoughts.”

Beyond OCD, a non-profit organization in Chicago, hosted the forum, where Emily talked about her disorder.

OCD affects about 2.2 million American adults, one-third of whom develop symptoms as children, according to the National Institute of Mental Health.

Common symptoms include having obsessive concerns about behaving morally, committing blasphemy or committing sins, and going to hell, according to the International OCD Foundation.

Obsessions are the things that scare people and make them feel stressed, and compulsions are the things that make them feel better, said Dr. Alec Pollard, founder and director of the Center of OCD and Anxiety-Related Disorders.

“Usually they’re questioning whether they have sinned or whether they are immoral, and they question that to a fault,” Pollard said.

Cassiday recalled one Jewish patient’s obsession – she refused to undress near a rabbi’s portrait in her bedroom.

Although research is limited, studies suggest that scrupulosity can reach 40 percent of people in some Muslim populations, Cassiday said.

Studies conducted between 1995 and 2002 in the U.S. found that between 5 to 33 percent of OCD patients experienced religious obsession, with less secular societies like Egypt and Saudi Arabia showing rates as high as 50 and 60 percent.

Scrupulosity has been with us for centuries and many prominent religious figures of the past may have battled with the disorder, including Martin Luther, Cassiday said.

Prior to founding the Lutheran Church in the 16th century, Luther was “banned from confession from his confessor priest because he did it so much,” Cassiday said.

Ignatius Loyola, who founded the Catholic Jesuit order in 1541, went for 18 months without shaving, cutting his nails or hair, experts said.

“Before he converted, he was very proud of his hair and his fingernails and his appearance,” and he felt he shouldn’t be so vain, Cassiday said.

Experts say ordinary rituals vary across religions, but religion does not cause OCD or the kinds of ritual behavior it ignites. Instead, OCD is known to be genetic and tends to run in families.

“It may be more prominent in more conservative segments than it is in less conservative segments, but even then it’s not that the religions are causing the OCD,” Pollard said. “It’s that the people who are predisposed are more prone to develop that in their religion if it’s a high priority.”

Cassiday says scrupulosity isn’t always related to religious obsessions. For example, she’s treated scrupulous vegans.

Experts say cognitive behavioral therapy is the most common treatment of scrupulosity. (Traci Badalucco/Medill)

Cassiday spent 13 weeks treating Emily, using exposure and response prevention therapy, where patients confront their fears.

In exposure therapy, receptors in the brain are saturated and don’t have time to produce new ones on the spot, so physical discomfort comes down, Cassiday said, and each time it becomes easier.

“The first time your anxiety goes way up, and if you do nothing to escape it, if you stay with the thought, stay with the situation, your anxiety gradually comes down,” Cassiday said.

Experts say the best treatments for scrupulosity are cognitive therapy, the one Emily underwent, and medication.

“I had a Catholic patient who wouldn’t take communion unless she had a completely empty stomach so, in her therapy, she had to eat a Goldfish cracker right before she went up to get communion,” Cassiday said.

Therapy recovery time can vary from patient to patient, ranging anywhere from a couple of hours to months, experts said.

Emily’s mom, who found Cassiday online after feeling frustrated with numerous therapists who were using deep breathing and talking sessions with Emily, said it took some time to adjust to her daughter’s therapy, but that Cassiday was able to put her daughter on the right track.

“When you have a strong faith in God and your child’s therapy is to have sticky notes all over the house that say ‘I hate God’ and ‘I hate Jesus,’ it’s like wow, what is going on here,” Emily’s mother said.

Emily described her exposure therapy, which lasted more than three months, as “uncomfortable, scary and exhausting,” but a necessary step to getting healthy.

“Many times it has caused me to tremble and cry,” Emily said.

Beyond OCD, a non-profit organization in Chicago, recently launched a free virtual support line, where experts and patients share successful treatment stories with callers.

Sally Ruecking, the organization’s president and CEO, said people with scrupulosity prefer remaining anonymous.

“If they send an email through the OCD info email, they don’t even give a name,” Ruecking said.  “Most of these people think they are the only ones.”

People with scrupulosity often hide it from their loved ones and are embarrassed to come forward, Reucking said.

“They are so mired in their depression that they feel weird or strange,” Reucking said. “They are living with spouses, and they don’t even tell the spouse what’s going on.”

Emily said she’s thriving in school thanks to her therapy, and urged people suffering from scrupulosity to stop hiding behind anonymity and get help using the available resources.

“I am the healthiest, happiest, strongest and most confident that I’ve ever been today,” Emily said.

Photo at top: Scrupulosity, a form of OCD, involves obsessive thoughts about moral character and leads to self-identified rituals.(Traci Badalucco/Medill)