Current Psychiatry Reports

, Volume 12, Issue 4, pp 282–289

Scrupulosity: A Unique Subtype of Obsessive-Compulsive Disorder

Authors

    • Herzog Hospital
  • Jonathan D. Huppert
    • Department of PsychologyThe Hebrew University of Jerusalem
Article

DOI: 10.1007/s11920-010-0127-5

Cite this article as:
Greenberg, D. & Huppert, J.D. Curr Psychiatry Rep (2010) 12: 282. doi:10.1007/s11920-010-0127-5

Abstract

The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed.

Keywords

Obsessive-compulsive disorderSubtypesScrupulosityReligion

Introduction

The link between obsessive-compulsive disorder (OCD) and religion is perhaps most interesting when viewed historically and would seem to reflect the coexistence—either peaceful or antagonistic—of religious and secular mental health world views and explanatory models. The first known descriptions that are retrospectively viewed as OCD-like were all religious in content. The Jewish Mishna (completed in the second century) brings accounts of excessive concerns of housecleaning before the festival of Passover, while the Babylonian Talmud (completed in the sixth century) describes people who repeat their prayers, fearing their concentration was inadequate [1]. Malleus Maleficarum, a guide to identifying and trying witches published in 1487 by two Dominican monks and inquisitors, includes the following case:

When he passed any church, and genuflected in honour of the Glorious Virgin, the devil made him thrust his tongue far out of his mouth ... When he tried to engage in prayer, the devil attacked him more violently [2].

Ignatius of Loyola wrote the following in his autobiographical Spiritual Exercises [3]:

After I have trodden upon a cross formed by two straws, or after I have thought, said or done some other thing, there comes to me from without a thought that I have sinned; I feel some uneasiness on the subject inasmuch as I doubt and do not doubt; this is probably a scruple and temptation suggested by the enemy.

Although both of these cases implicate the devil as the source of evil, the descriptions fit OCD-type behavior.

The terms used to describe obsessions and compulsions during the Middle Ages in Europe are similarly religious: the term obsession meant forced inappropriate speech, “a compulsion to blaspheme or swear aloud in church ... referred to as the ‘Devil in the Tongue,’” [4], while scrupulosity was defined by Flecknoe [5] in 1658 as involving both religious overconcern and general indecisiveness. A caveat stressed by Cefalu [6] is that care should be taken before categorizing these behaviors as OCD. Loyola, Luther, and Bunyon are commonly referred to as OCD sufferers by writers seeking roots for today’s OCD, although in their time, their ruminations may have been normative and even healthy searches for salvation. What is also missing in the above-mentioned sources and in these religious leaders’ autobiographical accounts is the degree that the complaints caused severe and prolonged distress and affected their daily functioning.

Just as areas of creativity such as painting, literature, and music moved their near-absolute focus away from religion during the enlightenment in the 18th century, so did the expression and understanding of distress become secular. None of the terms used in 19th century France to describe OCD-like phenomena were religious [7], while in the seminal lecture by Lewis [8] to the Royal Society of Medicine on obsessional illness in 1935, he evaluated a series of cases and listed five main topics: dirt, orderliness, aggression, sex, and religion such that from having been the context and form of OCD in the Middle Ages, it became a minor expression of the disorder.

Scrupulosity and Culture

Case series of the frequency of scrupulosity among patients with OCD range from 0% to 93% (Table 1). The rates are generally higher in Muslim countries. In studies of Jewish OCD sufferers in Jerusalem, we initially reported 50% [9], and then 41% in a later, larger sample [10]. However, in a sample of ultra-Orthodox patients with OCD, 93% had religious symptoms [11], suggesting that the very wide range of findings reported around the world reflects the central role of religion in the lives of our patients and their communities rather than a cause of the OCD. No study to date has found that a religious upbringing induces OCD. However, if OCD develops in an individual who is very religious, his or her religiosity (how religious the person is) is likely to express itself in the OCD. That is, religious individuals are more likely to present with scrupulosity as their primary symptom if they present with OCD, but little evidence suggests that they are more likely to present with OCD.
Table 1

Percentage of patients with religious symptoms in samples of OCD sufferers in studies conducted around the world

Country

Study (year)

Patients, n

Patients with religious symptoms, %

Predominantly Christian

   

 United Kingdom

Dowson [42] (1977)

41

5

 United Kingdom

Stern and Cobb [43] (1978)

45

0

United Kingdom average

  

2

 United States

Swedo et al. [44] (1989)

70

13

 United States

Riddle et al. [45] (1990)

21

29

 United States

Foa et al. [46] (1995)

425

12

 United States

Eisen et al. [47] (1999)

77

10

 United States

Pinto et al. [48] (2006)

293

26

 United States

Garcia et al. [49] (2009)

58

38

 United States

Chavira et al. [50] (2008)

52

10

US average

  

18

 Costa Rica

Chavira et al. [50] (2008)

26

10

Far East religions (Buddhism and Hinduism)

   

 India

Akhtar et al. [51] (1975)

82

11

 India

Khanna and Channabasavanna [52] (1988)

410

4

 India

Jaisoorya et al. [53] (2008)

191

31

India average

  

12

 Japan

Matsunaga et al. [54] (2008)

343

8

Islam

   

 Turkey

Egrilmez et al. [55] (1997)

45

11

 Turkey

Tek and Ulug [56] (2001)

45

42

 Turkey

Tükel et al. [57] (2005)

116

36

 Turkey

Karadag et al. [58] (2006)

141

20

 Turkey

Besiroglu et al. [59] (2007)

109

28

Turkey average

  

27

 Egypt

Okasha et al. [60] (1994)

90

60

 Bahrain

Shooka et al. [61] (1998)

50

40

 Saudi Arabia

Mahgoub and Abdel-Hafeiz [32] (1991)

32

>50

Other Middle East average

  

52

 Judaism

   

 Israel

Greenberg and Witztum [10] (1994)

34

41

 Israela

Greenberg and Shefler [11] (2002)

28

93

aOnly among ultra-Orthodox Jews, so samples differ significantly

Thought-action Fusion in Scrupulosity

A significant body of literature has demonstrated that individuals with OCD in general have a tendency to treat thoughts as equivalent to actions (known hereafter as thought-action fusion [TAF]) [12]. TAF is divided into two main categories: 1) the belief that the thought is likely to increase the probability of an event to occur and 2) the immorality of having the thought. The literature is more consistent in suggesting that TAF is likely related to all forms of OCD. On the other hand, there are suggestions that moral TAF is particularly related to scrupulosity [12, 13, 14••]. Thus, intrusive thoughts of harm, sex, or sin are thought to represent moral failure of the individual (usually suggesting that the individual having the thought is a sinner), equal to one who actually engages in any of these acts. The concept that thoughts and actions may be equivalent can be found in several Western religious sources, particularly in the Christian Gospel (“You have heard that it was said ‘You shall not commit adultery’; but I say to you, that everyone who looks on a woman to lust for her has committed adultery with her already in his heart”) (Matthew 5:27–28; New American Standard Version). Although there are also sources for this concept in Judaism [15] and Islam [16], these are not seen as part of the central dogma in the way they are in Christianity. Indeed, religiosity and religion (Christian vs not) interact to determine the extent of moral TAF in non-OCD individuals such that Christians—particularly more religious Christians—tend to have higher levels of moral TAF [16, 17••, 18]. Some have taken the increased moral TAF in religious groups to suggest that TAF may be a vulnerability factor for OCD, particularly scrupulosity, via indoctrination of moral beliefs about the sinful nature of thoughts (TAF) [12, 14••]. However, Siev et al. [17••] recently showed that it may be quite the opposite: although religious Christians did demonstrate more TAF, the relationship between TAF and obsessive-compulsive symptoms (in a healthy population) was nonsignificant, whereas in a Jewish sample, the presence of TAF was unrelated to religiosity but related to greater obsessive-compulsive symptoms (also in a healthy population). Thus, it may be that TAF is a risk factor when it is not normative, but among religious Christians, the teaching of such beliefs may in fact diminish moral TAF’s relationship to OCD and scrupulosity.

Is Scrupulosity Distinct From Obsessive-Compulsive Disorder?

The area of nonpsychotic disorders has been undergoing a process of unpacking and repacking during the past few decades, with OCD a prominent case and calling for it to be separated from anxiety disorders and included instead as its own superordinate category of obsessive-compulsive spectrum disorders [19], and various subgroups to be seen as separate categories, from hoarding [20] to scrupulosity [14••]. A review on scrupulosity has called for its separation from OCD for the following reasons: 1) sufferers have less insight, more fixity of belief, and magical thinking; 2) response to accepted treatment is less impressive; 3) the thoughts of sufferers are not experienced as inappropriate and intrusive, as is characteristic of OCD; 4) the Penn Inventory of Scrupulosity (PIOS) does not correlate highly with measures of OCD; 5) it is a distinct group of symptoms; and 6) it may overlap with obsessive-compulsive personality disorder (OCPD) as much as OCD [14••].

Scrupulosity is a term that originated in apothecaries’ weights—the tiniest of weights that only affected the most sensitive of scales [21]—and entered the religious vocabulary to describe people with overconcern and hesitation concerning all areas of appetitive behavior [22] and commonly “assailed by naughty and blasphemous thoughts” [23]. In the absence of psychiatrists plying their trade at the time, it is unclear how much these concerns were viewed as pathological or whether there was a spectrum of the condition from healthy to unhealthy religiosity. The term is now increasingly used in the mental health field to be synonymous with religious symptoms of OCD.

The finding of decreased insight, greater fixity of belief, and magical ideation in patients with scrupulosity versus other types of OCD was noted by Tolin et al. [24]. Our observations from working with religious patients with scrupulosity concur with these findings. However, the explanation may be that the topics that concern patients with scrupulosity arise from normative religious concerns [10], so that in contrast with secular thinking, the distinction between normative religious concerns and pathological obsessive concerns may be more nuanced (see below). Similarly, preliminary findings indicate that religiosity itself is associated with magical thinking [25, 26]. The measures used in the Tolin et al. [24] study therefore require replication with a normative religious sample, as the features that they found to be associated with scrupulosity may be normative features of religiosity.

The claim that scrupulosity is less responsive to recommended treatments is based on the findings of Alonso et al. [27], who studied 60 outpatients with OCD who were offered pharmacotherapy and behavior therapy, followed up after 1 to 5 years, and found that 63% (38 of 60) showed significant improvement. The only factor associated with poor improvement was sexual/religious obsessions in the Yale-Brown Obsessive-Compulsive Scale. However, only 2 of the 12 patients categorized as having either sexual or religious symptoms had religious symptoms, making the sample too small to draw conclusions. Fallon et al. [28] treated 10 patients with “moral or religious scrupulosity” with fluoxetine or clomipramine. Six were much improved at 3 months, and another two improved during continuing treatment, a response comparable to other pharmacotherapy trials for OCD. Abramowitz et al. [29] found that individuals in the religious/sexual thoughts category of OCD symptoms had no different response to exposure and response prevention therapy (ERP) than individuals with other subtypes with OCD, although one cannot determine the number of individuals who had only religious symptoms from their study. Huppert et al. [30•] reported that 9 of 12 ultra-Orthodox patients with scrupulosity were much improved after ERP—outcomes similar to those of most trials of ERP for OCD. The one study that found a significantly poorer response to cognitive-behavioral therapy (CBT) in patients with OCD was conducted by Mataix-Cols et al. [31], who found that individuals with religious or sexual obsessions tended to respond less well to behavior therapy, especially that administered by telephone. Given the combination of sexual and religious obsessions and the unique form of administration of this treatment, it would seem questionable to make too many extrapolations related to treatment responsivity of scrupulosity from this study, especially given the other findings.

The observation that patients with scrupulosity do not experience their thoughts as inappropriate and intrusive may be understood in the same way as insight and fixity of belief. OCD sufferers who are concerned that they have not said their prayers with adequate concentration or did not wash adequately before prayers (symptoms described by Muslims [32] and Jews [10]) are being true to the guides of religious law. Most coreligionists know the laws but are untroubled by these concerns when they pray. OCD sufferers may initially be seeking to be scrupulous (in a nonpathological sense), but the problem grows until functioning is severely affected. The initial concern was appropriate, the eventual consequences destructive. In addition, our clinical sense is that although some individuals do not describe their symptoms as inappropriate or intrusive, a significant number do.

The authors argue that scrupulosity is distinct in terms of epidemiology [14••]. Surprisingly, their support for this claim is the finding that the PIOS does not correlate highly with measures of OCD. Given that the PIOS was developed in a nonclinical sample [33], one cannot extrapolate to epidemiology from that study. In addition, the correlation of various subtypes of OCD and severity scores of OCD in general is not necessarily higher than that of the PIOS with measures of OCD [34]. Furthermore, the PIOS is a 19-item questionnaire that contains two subscales, one measuring the fear of having committed a religious sin and the other measuring the fears of punishment from God [33]. With personal knowledge of religious Judaism and having interviewed many ultra-Orthodox sufferers from scrupulosity, the fear of punishment due to having sinned is not a central theme of Judaism or of our patients’ world views. Judaism places emphasis on halacha—carrying out religious practices—but not out of fear of retribution. On the other hand, the PIOS includes no items on compulsive religious rituals, which are present in most of our cases. At face value, the PIOS does not seem sensitive for some Jewish or Muslim patients. The initial evaluation of the PIOS was done on a student population. More religious Protestant students scored significantly higher than less religious Protestant students. Both subscales were very low among Jews, with more religious Jews scoring even lower than less religious Jews [33]. Overall, PIOS scores were very low (average score, 18.98 of a possible 76), and the authors concluded it measured “scrupulous obsessions and compulsions in a nonclinical sample” [33], which is interesting given that it only asked about fears. Nelson et al. [35] administered the PIOS to 71 individuals with OCD. The average score for Protestants was 33, whereas Catholics and agnostics scored on average 20 and 19, respectively (similar results to those of the nonclinical sample in [33]), and the PIOS score was not associated with religiosity. Although one of the authors of the current article (Dr. Huppert) has some preliminary data supporting the discriminative validity of the PIOS in patients with scrupulosity, this does not suggest that these patients do not present with other OCD symptoms as well [11].

Supporting their claim that religious OCD “represents a thematically distinct and unified group of obsessions,” Miller and Hedges [14••] describe scrupulosity as consisting of obsessions alone, bar the occasional need for confession or reassurance. This is in marked contrast to our patients, whose symptoms are grounded in the Jewish religion (with similar descriptions from Islam) and have pronounced compulsive behavior (eg, lengthy preprayer washing compulsions, checking for abrasions before ritual immersion, and repeating of prayers). Furthermore, most of our patients have nonreligious symptoms of OCD. In a study of 28 ultra-Orthodox Jewish sufferers from OCD, we found that 26 had scrupulosity and 18 nonreligious OCD [11]. There was no significant difference between religious and nonreligious symptoms of OCD in terms of the distress, resistance, sense of irrationality, and hours spent daily, suggesting that scrupulosity and nonreligious OCD were remarkably similar and were different expressions of the same disorder.

The inclusion of scrupulosity into OCPD rather than OCD is a complex suggestion. OCPD as defined in the DSM-IV, having grown from edition to edition of the DSM, has given rise to much debate. Fineberg et al. [36] suggested that given the many commonalities between OCPD and OCD, such as gender, age at onset, chronicity, celibacy, comorbidity with depression and anxiety, heritability, and response to selective serotonin reuptake inhibitors, OCPD could be integrated usefully into the obsessive-compulsive spectrum of disorders. The DSM-IV definition of OCPD requires four of eight features. If we consider a patient who spends hours repeating a line of his prayers for fear he was not concentrating adequately and thus cannot complete his prayers in the time prescribed by the religious codes, it is clear he is preoccupied with details, a perfectionist who cannot get on and enjoy life, and rigid, giving him a diagnosis of OCPD, or are these circumscribed to his symptom rather than character traits? In many cases, we see that it is the former rather than the latter. The discriminating features between scrupulosity and religiosity are considered below.

Normal Religiosity Versus Scrupulosity

For the mental health expert with limited knowledge of religious beliefs and rituals, it may be difficult to differentiate healthy religious concerns and rituals from pathological obsessions and compulsions. In a preliminary investigation, Rosmarin et al. [37] demonstrated that secular individuals had trouble differentiating normative Jewish rituals from OCD rituals, whereas religious individuals were able to differentiate between the two. Thus, most coreligionists will not share the difficulty of differentiating compulsive from normative rituals, so knowledge about normal beliefs and practices should be acquired by the mental health professional. Based on our clinical experience of religious OCD in the ultra-Orthodox Jewish community, certain conclusions have been apparent [9]. The content of the obsessive concern is usually normative, the commonest being, in men, whether prayers have been said with sufficient attention or whether the praying individual is adequately clean before prayers, and in women, whether they are adequately clean before ritual immersion or adequately punctilious about dietary laws [10, 38••]. Jewish codes recommend care in these matters. However, even a single repetition is unusual, possibly virtuous, whereas many repetitions are suggestive of a problem. People suffering from scrupulosity usually have a particular concern in one area of practice, whereas the devout are careful in all areas. Religious compulsions are usually so time consuming that they affect the sufferer’s general level of observance, so that a person preoccupied with preprayer cleaning may actually miss the allotted time for prayers. Similarly, rituals may be so time consuming that no time remains for religious study, the most valued aspect of ultra-Orthodox life. The areas of concern are often of minor religious import but resemble the concerns commonly found in OCD (eg, cleanliness and exactness resulting in washing and checking). On occasion, our patients have been so concerned with their particular “scruple” that they have transgressed in other, more important areas of practice.

Unique Issues Related to Treating Scrupulosity

Ultimately, we view the treatment of scrupulosity, whether it be via pharmacotherapy with encouragement of exposure and reduction of compulsions, or systematic CBT including exposure and response prevention, as requiring some special considerations. Given the unique features of scrupulosity and their potential interaction with religious beliefs, the tailoring of the treatment needs for patients with scrupulosity (especially religious patients) is the epitome of the Sackett et al. [39] definition of evidence-based practice. That is, the integration of the best current empiric findings from research with clinical expertise and patient preferences (or values) related to assessment, the therapeutic stance, motivating the patient, challenging of obsessional beliefs, and the involvement of clergy. More detailed accounts of these and other issues more specifically related to CBT for scrupulosity are available elsewhere [30•, 38••].

Assessment

While we along with most experts in OCD contend that scrupulosity is a subtype of OCD, we agree that there are unique issues related to treating scrupulosity that are essential for proper treatment. As with most psychiatric disorders, the first issue we have addressed previously: proper diagnosis. One issue that arises from our above discussion is the likelihood of presenting with scrupulosity. It is important to note that atheism, agnosticism, and liberal forms of religious adherence do not inoculate one from being at risk for scrupulosity. We have seen people who describe themselves as secular or liberal manifesting various forms of scrupulosity (eg, fear of hell; fear of consequences of violating a religious dictate, such as kosher dietary restrictions despite not believing that one needs to do so). On the other hand, our examination of the data does suggest that devout individuals are more likely to present with scrupulosity if they present with OCD symptoms (ie, they have such vulnerabilities). We have found that the standard Yale-Brown Obsessive-Compulsive Scale assessment of OCD often lacks necessary details that are required to evaluate scrupulosity more thoroughly. The Yale-Brown Obsessive-Compulsive Scale checklist has two global questions, one about fear of religious violations and one about fear of moral violations. A more detailed inquiry using one’s knowledge of the general culture and the specific religion is required.

Therapeutic Stance

How the patient views the therapist (pharmacotherapist or psychotherapist) affects many issues related to treatment (motivation, adherence, and outcomes). With the scrupulous patient, a delicate balance should be struck: on the one hand showing that the patient’s symptoms are, indeed, symptoms of a disorder, while on the other hand demonstrating respect for the patient’s religious beliefs and values. One’s own religious beliefs may serve to the benefit or the detriment of this balance. Religious patients may be more willing to trust a therapist who exhibits some expression of faith, but they also may attempt to use the therapist as a proxy for reassurance (in addition to or in place of a religious authority). It is helpful to ensure that the patient understands that the goal of treatment is not to rid the patient of his or her religious beliefs or practices but to help the patient live a religious life more fully and to show that the current symptoms are interfering with this endeavor.

Motivating the Patient

Oftentimes, religious patients who have scrupulosity are ambivalent about seeking treatment for their symptoms. Perhaps these thoughts and behaviors are necessary to avoid sin? Perhaps they are necessary punishment? What if stopping the rituals leads to a reduction of one’s religious fervor? There are several approaches to dealing with these issues, which may otherwise decrease motivation for treatment. First, most religions do not expect perfectionism from their adherents. People are expected to try their best but also expected to fall short at times. It is within this framework that the religious scrupulous patient gets stuck: is it not necessary to devote an excessive amount of energy to “try one’s best”? Here, the idea that there are usually other competing positive values within the religion is essential. One is not only supposed to avoid sin or engage in a single act perfectly, one is supposed to act in some positive way to serve God. The patient’s symptoms are in fact interfering with that service. One aspect that may serve as a point of contention here is whether the therapist should be encouraging the patient to accept sinning. Our stance is that it is not the sin itself that should be accepted, but the risk of sin. One cannot reduce the risk of one sin to zero without elevating the risk of other sins or becoming completely dysfunctional. Thus, accepting some risk of sin should be the patient’s goal.

Challenging of Obsessional Beliefs

There are many beliefs with which the scrupulous patient often presents. Many of these are similar to the beliefs that other patients with OCD have (overestimation of threat, TAF, that compulsions are necessary to reduce anxiety or prevent feared outcomes). The belief that all thoughts of sin or immorality are forbidden is one of the main beliefs that needs to be addressed in treatment. It is usually helpful for the patient to differentiate intentional thoughts from unintentional thoughts. The former are typically what religious dictates related to proper beliefs refer to—most religions will not hold a person accountable for thoughts that he or she did not purposefully elicit. Given that scrupulous obsessions are unintentional, intrusive thoughts that elicit anxiety or distress (by definition), the therapist can communicate that such thoughts are not the responsibility of the patient and therefore should not require neutralization, atonement, or penitence. Another differentiation is that between thoughts and actions (TAF). A metaphor that can be useful for many patients is one in which the patient imagines two people in the room: one is a mass murderer who is thinking about how much he loves his mother, and the other is a distinguished clergy who has dedicated his or her life to acts of charity (eg, Mother Theresa) but who has unintended, intrusive thoughts about harming children and blasphemy. Which person is bad? Such an inquiry can help emphasize that thoughts alone are not sufficient to determine sin, that the intent and one’s actions are necessary.

Involvement of Clergy

Recent discussions of the inclusion of religious authorities in treatments of scrupulosity suggest that clergy involvement can be helpful at times and is sometimes essential [1, 30•, 38••, 40]. In fact, a recent study supports our clinical experiences that many clergy do not feel capable of managing issues of scrupulosity alone [41]. Overall, direct discussion with the patient’s religious authority, with the goal of coming to a mutual understanding and collaborative approach to assisting the patient in reducing his or her suffering, usually can be accomplished. Involving the patient together with the authority is usually the most effective approach.

Conclusions

Scrupulosity started as one of the representative cases of OCD but slowly seems to have become less common as societies have become more secular. Indeed, in more traditional societies, rates of scrupulosity seem to be higher still today. However, it does not appear that religion causes OCD, but rather that it influences its manifestation such that religious people are more likely to have religious symptoms. Few data suggest that religion causes vulnerability to OCD (via TAF or otherwise). In addition, epidemiology and phenomenology of scrupulosity argue for retaining it as a subtype of OCD. Notwithstanding its classification, unique issues must be addressed in the treatment of scrupulosity, especially in religious patients. Sensitivity to religious issues is an essential part of any treatment of such cases.

Disclosure

No potential conflicts of interest relevant to this article were reported.

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