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Scrupulosity (Religion) OCD

By George Maxwell, CBT Therapist

Scrupulosity OCD, also sometimes called Religious OCD, is a subtype of OCD in which the individual experiences significant distress in relation to intrusive thoughts about God, morality and their spirituality.

Although the content of Scrupulosity OCD relates closely to the individual’s beliefs around how good, moral or holy they are in the eyes of their religion or God, the actual processes involved in the disorder are characteristic of OCD in general and as such, are able to be treated.

This article looks at the specific features of Scrupulosity OCD, how it is maintained and how Cognitive Behavioural Therapy (CBT) with Exposure and Response prevention (ERP) can work as an effective treatment.

There are many subtypes of OCD, each with different “themes” influencing the content and how it manifests behaviourally.  For instance, with the more commonly experienced Contamination OCD, the sufferer is obsessed with maintaining excessive levels of cleanliness for fear that they may catch and spread germs to others causing them illness.

They might have an intrusive thought such as, “there are germs everywhere – The children will get sick and die.”  They will then experience anxiety and emotional distress and then engage in all sorts of cleanliness and hygiene related behaviours (e.g. handwashing, cleaning, avoidance) to reduce the chance of the intrusion coming true and to reduce their distress.  Because these compulsive behaviours lead to a reduction in distress, the behaviours then get repeated whenever the intrusive thoughts arise again.

Scrupulosity OCD works in exactly the same way – Intrusive thought leads to distress which leads to compulsion, but rather than having manifesting in terms of keeping things clean, it presents in themes relating to Religion, God and Morality.  Here’s a case example:

Scrupulosity OCD case example : Tina

Tina was a 35 year old woman who visited church regularly.  One week at the church service, whilst the priest was delivering the sermon, almost out of the blue she experienced the thought “I don’t give a f*ck what God thinks.”  This shocked her.  Of course she cared what God thinks.  But here she was, in church of all places having this thought about God.  She started to doubt herself – why did she just blaspheme?

Tina tried to push the thought away but it bounced back more intensely than before.  The thought wouldn’t go away no matter how hard she tried to push it out of her mind, leaving her feeling more and more anxious.  She found it difficult to look at the priest whilst he was speaking – how could a blasphemer even look him in the eye?  She felt nervous and sickly throughout the rest of the service.

When she got home she went to her bedroom, took out her bible and began to read through it.  She did the sign of the cross and then started to pray to God to apologise for having had the thought.  After a while her anxiety and distress lessened and she started to feel better.

Tina was troubled by the experience and wanted to make sure that it didn’t happen again.  To ensure this, she tried to make sure that she thought more “Holy” positive thoughts and was very attentive to the possibility of any thoughts that she thought could be blasphemous.  Inevitably, when she went to pray before bed that night the intrusion occurred again.  This time it felt really vivid and intense and, despite trying to push the thought away, it remained as loud and as potent as ever.  It was followed by other similar thoughts which Tina believed to be disrespectful and unloving towards God.  That night, Tina hardly slept a wink.

Over the next few days and weeks, Tina became obsessed with her intrusive thoughts.  She read her bible more, prayed and did the sign of the cross every time she had an intrusion (which was often) and stopped going to church.  She promised herself that she would go back to church when she is better but she believed that there was no way that God would want him in his house if she was having thoughts that disrespected him.  More deeply, she believed that she must secretly not really love God.  Her intrusive thoughts made her doubt whether she ever had done and whether she ever would again – This made her feel upset, sad and alone.

We can see here how an intrusive thought, one that Tina feels is not in line with her beliefs about God, can lead to distress and have a huge impact upon the OCD sufferers functioning.  Next, let’s look at the key factors that keep the OCD going.

A detailed look at what keeps Scrupulosity OCD going

Let’s break down exactly what happens in the maintenance of Scrupulosity OCD.

As mentioned earlier, Scrupulosity OCD relies upon the same processes as other types of OCD to keep itself going.  This means that we begin with an intrusive thought which in this case will be one related to God, Religion or Morality in some way.  The individual then appraises this intrusive thought in a way that to them creates anxiety and emotional distress.

An example of an appraisal of an intrusion might be something like, “Having this thought means that I’m an evil person.

Appraisals in OCD are really important for us to think about because it is the appraisal of the intrusion that actually creates the distress and not the intrusion itself.  We have thousands of different thoughts every day, some of which may be unusual and don’t necessarily fit in with our values, beliefs or how we see ourselves and yet, rather than us become distressed by them, we are typically able to dismiss them and forget about them without much problem.

However in OCD, our appraisals of intrusive thoughts usually relate to the thought being something that is particularly harmful, significant or otherwise something that goes against what we hold to be true about ourselves and our beliefs.  This last part, in which we appraise our intrusions as being something that conflicts with our deeply held beliefs about who we are, is called “Ego dystonic.

If I hold my religion and my faith in God in the highest regard and it is such a fundamental element of who I believe myself to be in the world, then to experience an intrusion in which I reject or offend God, causes me distress because it is Ego dystonic.

There are other ways of thinking at the level of our appraisals that contribute to our distress in response to the intrusion.  These include overestimation of the importance of intrusions, intolerance of uncertainty, exaggeration of responsibility and Thought-Fusion biases.

So, we appraise the thought as being something that is potentially threatening and as such, our body responds with the appropriate emotion: Anxiety.  Anxiety is an emotional response to danger that we are “hard-wired” to experience.  It sends signals throughout our body to activate the fight or flight response to enable us to Fight or Flight (escape) from the perceived threat.

So, what do we do here?  This is where our compulsions come into play.  A compulsion in OCD is a behaviour that we employ to prevent an intrusion from coming true, to make reparations or to reduce our overall level of distress.  So, in OCD in which the individual experiences intrusions about causing harm to people we might see compulsive behaviours in the form of for instance hiding all dangerous objects, or avoiding being with people who they don’t want to hurt.  They may also engage in trying not to think the thought (thought suppression), neutralising (e.g. responding to an intrusion with a “good” thought) or distraction.  These internal and external behaviours all contribute to a reduction in anxiety.  However, this reduction is short lived.

Compulsions only give short term relief because whenever the thought arises again, the only strategy we have to get rid of the distress associated with the thought is to repeat the compulsion.  This means that we never really get to see what would happen if we didn’t carry out the compulsion – would our intrusion or distress get worse?  If so, how much worse?  Does the compulsion really stop the intrusion from coming true?

Compulsive behaviours in OCD become negatively reinforced.  This means that because they give us short term relief from our distress then we are likely to continue repeating the behaviour.  This is why people with OCD get locked into repetitive behaviours which have a severe negative impact upon their lives.

CBT treatment for Scrupulosity OCD

The treatment with the best evidence for Scrupulosity OCD is Cognitive Behavioural Therapy (CBT) with a particular emphasis upon an intervention called Exposure and response prevention (ERP).  ERP works by exposing the individual to something which would trigger the OCD related distress and then having them not use their OCD responses or make using them have no effect.  More recent developments in OCD treatment also look at the role that thinking errors at the level of the appraisal and explore how these may be changed.  Behavioural Experiments are a big part of this.

Let’s begin by taking a look at Exposure and Response Prevention.

Exposure and Response prevention (ERP) for Scrupulosity OCD

Exposure and response prevention (ERP) is the treatment intervention for OCD which has the strongest evidence.  It involves deliberately, in a graded way, exposing the OCD sufferer to triggers for their intrusions and the underlying theme – This is the Exposure bit.  The response prevention (also called ritual prevention) bit is where we inhibit the use of the compulsive behaviours.

Whilst doing ERP, a process called habituation takes place.  This means that the anxiety associated with the exposure trigger reduces over time, without the client using any of their compulsive behaviours.  When this is done repeatedly and with more and more OCD triggers, the individual starts to learn to tolerate their intrusions and understands that they are harmless, without having to engage in any of their compulsive behaviours.

So, let’s look at an example with Tina.  Her intrusive thoughts cause her distress because she interprets them as potentially meaning that she doesn’t love God, and as such is a bad or evil person.  So, we want to create exposure and response prevention interventions around this theme.  We have a choice of how we do this.  We could get her to go to church with one of her intrusions written on a piece of paper in her pocket – “I hate God.”  Throughout the service we could get her to occasionally (discretely) read the piece of paper (the exposure) and when she feels distress, to then not try to pray for forgiveness, do the sign of the cross or another of her compulsions (the response prevention).  This type of ERP task, taking place in an actual physical situation, is called in-vivo exposure.

Although Tina will feel incredibly anxious to begin with, due to habituation her anxiety will reduce.  We would then get her to practice this scenario frequently.

Over time, the anxiety will reduce as she learns that:

  1.  she can tolerate the anxiety
  2. that the feared outcomes of her intrusive thoughts do not happen even when she doesn’t use her compulsive behaviours.

This diagram shows what happens to her distress over multiple ERP practices.

Graph showing reduction in anxiety in prolonged exposure to fears in exposure and response prevention

In-vivo exposure is just one type of strategy that we can use for ERP.  Another is Imaginal exposure.

Imaginal exposure is, as the name suggests, we use imagination to activate the fear response and, just like with in-vivo deliberately prolong exposure to the fear whilst inhibiting typical compulsive behaviours.  There are three ways that we can enact imaginal exposure in a case such as Tina’s.

        1. Get Tina to imagine the Intrusive thought itself repetitively over a prolonged period of time – “I don’t give a f*ck what God thinks.”
        2. Using imaginal exposure to imagine carrying out an in-vivo exposure task.  This is useful in serving as a graded practice before carrying out a particularly distressing in-vivo task.
        3. Imagining a feared consequence coming to fruition.  So for instance, at the core of Tina’s intrusive thoughts about God is the idea that she doesn’t love God and that she will go to hell rather than heaven.  We would get her to write out and then imagine in great detail exactly what that fear would look like – being judged by God, watching the rest of her family being accepted into heaven, being tortured in Hell.  Incredibly distressing stuff, but massively effective in facing the root fears in Scrupulosity OCD.

Cognitive treatment for Scrupulosity OCD

The “Cognitive” bit in CBT relates to the stuff that happens in our heads – our thoughts, memories, imagination and attention.  In OCD, we are interested in understanding how changes in our thinking can modify our response to the intrusive thoughts.  Remember, intrusive thoughts are a normal common phenomenon, however it is how we relate to them at the level of our appraisals that gives rise to the distress.

As such, the cognitive interventions we employ in Cognitive therapy for OCD typically target the appraisals that we give to our intrusions.  Such appraisals are typically prone to thinking errors (sometimes also called cognitive distortions), and if we identify that there are such errors that cause our distress, then it is these we need to modify.

Let’s start with a helpful technique which we call Theory A vs Theory B.

Theory A vs Theory B in Scrupulosity OCD

Theory A vs Theory B is a technique used in CBT to enable an individual to look at an alternative explanation for their problem and to gather evidence to see which of the two explanations might be the most likely to be true.  It often presents one Theory as being the client’s interpretation of the problem and the other theory as being a more psychological interpretation.

 

So in Scrupulosity OCD, we have the sufferer’s interpretation of their problem as Theory A.  In Tina’s case this might be phrased as, “My problem is that I don’t love God.”  Theory B is focused upon presenting a psychological interpretation of the problem, “My problem is that I worry that I don’t love God.”  See the subtle difference?  Theory A is basically what the OCD says whereas Theory B presents an alternative psychological theory.

What next?  Now we have the task of seeing how much evidence that we have for each theory.  It’s useful to remember here that we are looking for evidence the supports a theory, rather than one that definitively proves it.  So, the evidence that Tina might have for Theory A might be things like, “I have intrusive thoughts saying that I don’t love God, I’m avoiding church”

The evidence we have for Theory B might be things like, “I’m upset by the intrusive thoughts, so maybe I do care about God, I’ve been going to Church all of my life, I try to do good things in the eyes of God”.  Now based upon the evidence that we have for each theory, which one appears to be a more accurate theory to explain the problem?  Which one do we have more evidence for?  Spoiler:  We typically find that there is much more evidence for Theory B than there is for Theory A!

Finally, we want to move the exercise into the domain of behaviour.  We want to think about how we would act and live our lives in the case of each behaviour being true.  What should Tina do if Theory A is true?

Well, if it is true that Tina doesn’t love God, then she probably needs to stop praying.  She might as well drop out of the church groups and it probably doesn’t matter if she continues with the Christian charities that she’s involved in.  It probably means big changes in her life – Is this what she really wants?

 What if we have more evidence for Theory B – That the problem is that she worries that she doesn’t love God?

Well, if this Theory is accurate then she can start to stop giving herself such a hard time about the thoughts.  If she worries about not loving God, then her relationship with God must be important to her.  She can probably also relax and pay attention when she’s at church, and not feel the need to pray so much when she has intrusive thoughts.  In fact, she could probably, with the help of some more exposure and response prevention, start to drop her religious compulsions entirely.

Theory A vs Theory B is a great tool for us to really get to grips with what the OCD is telling us versus what might actually be going on.  Next we need to look at changing the way we think some more by using behavioural experiments.

Behavioural Experiments in Scrupulosity OCD

We saw earlier how exposure and response prevention can be an effective intervention in allowing the scrupulosity sufferer to find out both that their anxiety will reduce over time without using their compulsions and that the feared consequences will not come true without using these behaviours.  The proposed mechanism – the process that actually leads to the change – is called habituation.

Behavioural experiments, although often utilising habituation, focus more upon directly changing what we thing about the intrusions to bring about change.  The mechanism for change here is what we call Cognitive change.

The first step in setting up our behavioural experiment is to think about what thought we are going to test.  So in Tina’s case because she

So we have the belief to be tested:

“I should be able to control my thoughts at all times, especially at church.”

And the alternative:

“If I stop trying to control my thoughts, then nothing will happen.”

Then based upon our thought to be tested, we have Tina’s prediction:

“If I don’t control my thoughts at church, I’ll become a bad person in the eyes of God and be punished.”

It’s important to be clear at this stage just what Tina means by be punished by God.  Does she mean straight away?  Next week, next year.  Or will it be something that happens in the afterlife, in Heaven?  If it is a swift and just punishment, then what would this look like?  Are we talking about something happening to Tina or to someone else?

We need to be really clear just what is meant by this as we are going to test out the outcome of the experiment in relation to Tina’s expectations of punishment.

Next we decide on just how we will carry out the experiment.  We agree on Tina visiting the church and letting her thoughts come freely, without any degree of control, mental neutralising or compulsive behaviours.  We agree that she should aim to do this for the duration of just one service and at the end of it, and for the rest of the week, to keep a log of any bad things that do happen in relation to Tina’s definition discussed above.

We also practice not controlling thoughts whilst in the therapy session, just so that Tina can see how to do it.

Then Tina carries out the task.  When she returns to therapy the week after we discuss what happened, did the feared outcomes occur and what this means for her OCD and her future behaviour overall.  Has her belief about the consequences of not controlling her thoughts changed? We can also evaluate the outcomes of the experiment and decide whether it is something that will fit into her Theory A or Theory B columns.

Conclusions

We’ve covered here the basics of what scrupulosity OCD and how we can use CBT with Exposure and Response prevention to treat it.  Of course, this just scratches the surface of Scrupulosity and doesn’t convey how difficult and distressing a condition that it can be for the sufferer.  If you are struggling with Scrupulosity and want to arrange treatment, then you can contact me, George Maxwell at enquiries@accesscbt.co.uk or call 07887 701 176.