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One type of Obsessive-Compulsive Disorder (OCD) that is often hard to detect is scrupulosity. Scrupulosity is typified by religious obsessions in which individuals are driven by the fear that they are evil and could be doomed to punishment by their particular supreme being. Because the content and implications of the obsessions are so disturbing, people are hesitant to disclose the thoughts. Because religion is such a personal subject, therapists are often avoidant about addressing this type of OCD. The religious obsessions may include blasphemous or sinful images or thoughts; very disturbing immoral thoughts or desires; concerns about the morality of past actions; doubts about if one followed religious rituals perfectly; and possibly sinful behaviors. Those with scrupulosity may have frequent and distressing doubts about whether or not they sinned or offended and whether or not they meant what they said, did or thought. Scrupulosity may not only involve religious obsessions, but often involves obsessive mental rituals which are the compulsive behavior used to neutralize the anxiety. If the compulsions are obsessive, they are not readily visible to others. The types of mental rituals may include silent prayers, reassurance and phrases; trying to figure out the morality or intention of thoughts; or the repetition or representation of religious rituals or behaviors. Sometimes religious or symbolic gestures will accompany the mental ritual. Those with scrupulosity tend to rely on all-or-nothing thinking and perfectionistic expectations of adherence to a specific interpretation of a religious doctrine. They may seek counsel with religious leaders much more willingly than they would seek therapy. If they share their concerns with family and friends, they easily get reassurances. Among others, I have treated a number of young teens troubled by scrupulosity. This age group is particularly susceptible due the developmental constellation in which the ability to engage in abstract reasoning, increased independence from authority, and the emergence and awareness of sexual and aggressive impulses co-occur. The teens are usually bright, articulate, sensitive and kind kids who are compliant with treatment and get good results. I acknowledge the value of having a spiritual life and one’s religious beliefs. I treat the scrupulosity as I treat all types of OCD, using Exposure with Response Prevention and other Cognitive-Behavioral Therapy techniques. I prescribe gradual exposure to the blasphemous thoughts and images and teach the person how to stop ritualizing in the service of OCD. As I challenge the person to stop their rituals, I note that if they truly believe in a loving higher power they are not showing faith in that supreme being by needing to rely on special magical routines. I may ask them if they would hold others to the standards to which they hold themselves. I support their efforts, reminding them that their holy being does not want them to be in anguish. |
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