Scrupulosity: religious and moral OCD, symptoms and treatment in the UK

The NHS describes OCD as a mental health condition in which a person has obsessive thoughts and compulsive behaviours. An obsession is an unwanted and unpleasant thought, image or urge that repeatedly enters the mind, and a compulsion is a repetitive behaviour or mental act done to relieve the distress.

In scrupulosity the subject matter is religion or morality. OCD-UK lists examples such as fearing that sins will never be forgiven, fearing screaming blasphemous words in a religious place, worrying that prayers were omitted or said incorrectly, needing to repeat prayers, believing bad thoughts during prayer will contaminate or cancel out its value, and feeling one is always doing something sinful. The charity notes that the constant analysing of faith strains belief and often leads people to avoid church and religious practice altogether.

Scrupulosity is not limited to any one religion, and some people have moral rather than religious versions, such as being tormented by whether they have done something wrong. The Royal College of Psychiatrists describes how people with particularly high standards of morality and responsibility may feel it is terrible even to have a thought, and so watch out for it, which makes it come back more often.

The Royal College of Psychiatrists describes the three parts of OCD as obsessions, the emotions that follow (such as guilt, fear, disgust or depression) and compulsions. In scrupulosity they commonly look as follows.

• Repeated doubts about whether you have sinned, offended God or broken a religious rule.

• Unwanted blasphemous or sexual thoughts, particularly in places of worship or during prayer.

• Repeating prayers, rituals or confessions until they feel right.

• Seeking reassurance from clergy, family or friends again and again.

• Mentally reviewing the past or neutralising thoughts with counter-thoughts, as the Royal College describes.

• Avoiding religious places, texts or practices because of distress.

Faith and a healthy conscience can bring comfort and guide behaviour. In OCD the thoughts and rituals are felt as an unpleasant demand or burden. The Royal College of Psychiatrists notes that compulsions in OCD never give pleasure and are always felt as an unpleasant demand, and that practices that are pleasurable are different. The distress is out of proportion, takes up a great deal of time and gets in the way of daily life and of the worship the person values.

A religious leader can help to distinguish ordinary spiritual questions from OCD, as the Royal College says, but clinical treatment for OCD is usually needed as well. Many leaders are unfamiliar with OCD, so it is worth telling a clinician about your faith so that treatment respects your beliefs, and telling your faith community only what you are comfortable sharing.

The NHS says it is not clear what causes OCD, and lists family history, differences in the brain, life events such as bullying, abuse or bereavement, and personality, including a strong sense of responsibility for oneself and others. The Royal College of Psychiatrists adds that stress brings it on in around one or two in three cases, and that the genetic picture is complex.

People with scrupulosity are often conscientious, caring and moral. That strength can become a vulnerability when it turns into a demand for certainty that cannot be met.

The NHS says you can refer yourself to an NHS talking therapies service in your area, or see a GP, who will ask about your symptoms and can refer you if needed. People with OCD are sometimes reluctant to seek help because they feel ashamed or embarrassed, but the NHS says OCD is a health condition like any other. Having it does not mean you are mad, and it is not your fault.

It can help to explain to your GP or therapist what the thoughts are about and how they affect your life. Treatment focuses on how you respond to the doubts and fears.

The NHS says the main treatments for OCD are CBT, usually, and an SSRI antidepressant. CBT often has an effect quite quickly, SSRIs can take up to 12 weeks, and if they do not help an alternative SSRI, a combination or clomipramine may be offered. The Royal College of Psychiatrists describes exposure and response prevention (ERP), in which you build a list of feared situations or thoughts, start with the least feared, and face them without doing the ritual or seeking reassurance until the anxiety falls, and cognitive therapy, which helps you stop fighting thoughts and change your reaction to them.

For scrupulosity, ERP might include writing or listening back to a feared thought, or leaving a prayer unrepeated, while resisting the urge to put it right. Cognitive therapy can address beliefs such as thinking it will make it happen, or that having a thought is as bad as acting on it. The college says about 3 in 4 people who complete ERP are helped a lot, and that about 6 in 10 improve with medicine.

The Royal College of Psychiatrists suggests that you remind yourself that it is not your fault, resist the compulsion rather than the thought, avoid alcohol or street drugs to control anxiety and contact support groups. Charities such as OCD Action, OCD-UK and TOP UK, which the NHS lists, offer information and peer support.

Practising your faith in a way that does not feed the compulsions can be part of recovery. Many people find that treatment brings back the peace and meaning that OCD had taken from their faith.