Scrupulosity

of medieval apothecaries. The word scrupulosity is derived from the word scruple. The latter is derived from the Latin term ('small rock'), such as the kind of small rock that one would get in their shoe while walking which later carried a sense of mental uneasiness. A later semantic shift in the jargon used by apothecaries led to scruple meaning 'one twenty-fourth of an ounce', a measure which would only be noticed on extremely sensitive scales. This sense developed in vernacular English to mean an inconsequential moral interpretation which could only bother an overly-sensitive mind. ==Classification==

Traditionally, scrupulosity has been treated as a subtype of obsessive–compulsive disorder (OCD) and such categorization remains the majority opinion. Under a four-prong model of OCD, it is categorized as a subtype manifesting as obsessions of unacceptable thoughts which seek out reassurance-based compulsions. In a five-prong model based on factor analysis, it belongs to a category of "religious, sexual, and aggressive obsessions" with no explicit compulsion model. Some clinicians have pushed for scrupulosity to have a distinct diagnosis from OCD since at least the early 1990s. Patients with scrupulosity exhibit similar symptoms to those with OCD, but typically have "poorer insight, higher fixity of belief, greater perceptual aberration, and more severe magical ideation". The obsessive thoughts of those with scrupulosity differ from diagnostic guidance as the obsessions are about pertinent real-life problems. Similarly, compulsions found in OCD are typically irrational and intended to minimize anxiety, whereas those of scrupulosity are typically excessive but logically informed and intending to solve the issue. Critics of this view argue that functional evidence clearly demonstrates overwhelming similarity with OCD, even if there are some noteworthy topographical differences. Other kinds of OCD which manifest as unacceptable thoughts show nearly identical neutralization strategies and follow similar cyclical patters. Co-occurrance with other forms of OCD, especially with obsessions about sex and violence, is also a common argument for categorizing scrupulosity as a form of OCD. ==Signs and symptoms==

Scrupulosity is a psychological disorder in which an individual experiences distressing and maladaptive obsessions regarding moral or religious issues and compulsive behavior which attempts to mitigate the distress caused by such obsessions. Those with scrupulosity exhibit multiple dysfunctional lines of thought, including placing undue emphasis on the role of their thoughts, an excessive need for control, a heightened sense of responsibility, and an impaired ability to estimate threats. Though mostly associated with religion, scrupulosity has been found in irreligious people where it manifests as fears of being immoral or bad. The disorder is marked by two primary archetypes: obsessions of wrongdoing with compulsions seeking reassurance and obsessions of punishment with compulsions of avoidance and of repentance. In most individuals, some combination of both archetypes are present. Coreligionists, including clergy, often view such behavior as guiltless, easily pardonable, or otherwise of unimportant, but it causes significant distress in patients. The disorder is extremely idiosynchratic and heterogeneous, meaning that manifestations vary widely from person to person and may be derived from a variety of etiologies. For example, religious icons may be sought out by one individual with scrupulosity for comfort and avoided by another for fear of triggering religious obsessions. Obsessions . Individuals with scrupulosity have "a habitual state of mind" in which dysfunctional moral or religious thought patterns pervade, and feelings of guilt and personal responsibility are disproportionately amplified. These religious obsessions are sometimes known as scruples. Being irrationally fearful of sinning, they believe their own licit behavior is sinful or that their sinful behavior is more transgressive than it really is. Intrusive thoughts about committing blasphemy, sexual immorality, and other immoral actions in the past or the future are commonly reported, as are thoughts that a religious duty has been performed improperly or the individual will be divinely punished. Other common themes include that one is unwittingly committing a sin, feelings that one may lose control and become immoral, doubts about faith, fears that one's worship will not be accepted by God, fears of going to hell. Patients often feel that they are improperly penitent or that they are uncertain if their intrusive thoughts are wanted or not. They exhibit more negative ideas about God, envisioning the deity as "punishing, fearsome, jealous, terrifying, angry, [and] vengeful", which scales with disorder severity. The manifestation of obsessions varies based on religion and cultural context. Obsessions generally fall into four categories, which often overlap: • Blasphemous intrusive thoughts (egodystonic; e.g., a Christian with intrusive thoughts of Jesus on the Cross with an erection) • Concerns about orthodoxy (egosyntonic; e.g., a Catholic who cannot reconcile his intellectual thoughts about abortion with his religious conviction and repeatedly asks his priest if he is still in good standing with the Church) • General intrusive thoughts viewed through a religious lens (generally egodystonic, typically resolved with religious-themed compulsions; e.g., a man who has incestuous intrusive thoughts about his sister, blames the Devil, and prays excessively) • Doubts about faithfulness or whether religious obligations have been appropriately followed (e.g., a Mormon woman who worries that by wiping after using the restroom, she is masturbating and thus is failing to appropriately follow her religious code) Ironically, the typical narrowness of obsessions are so rigid and excessive that they often cause the person neglect more important aspects of their faith. In one case, a woman was so preoccupied with her fear of having blasphemous intrusive thoughts during a religious service, that she avoided them altogether. Overall, patients with scrupulosity exhibit more obsessive thoughts than other patients with OCD. Scrupulosity is associated with moral thought-action fusion, a disordered pattern of thought that equates thoughts with actions, irrespective of if the thoughts are wanted or not. For example, an intrusive thought about having illicit sexual intercourse may compel a person with scrupulosity to bring the thought to confession – sometimes repeatedly – as if they had actually committed the sexual act, even though the thought was not willingly generated by the individual and the individual never physically engaged in such an act. Religious prohibitions against certain kinds of want may promote the occurrence of thought-action fusion in people with scrupulosity, such as the Tenth Commandment which prohibits coveting and Jesus's admonishment in the Sermon on the Mount that a man who looks at a woman in lust has already committed adultery in his heart. Thought-action fusion is more common in Christian patients than patients of other religions. Intolerance of uncertainty Intrusive thoughts, including those about religious topics, are not themselves disordered; healthy individuals will intermittently experience intrusive thoughts, acknowledge them as absurd, and discard them. Scrupulosity does not manifest in most religious people because they recognize that thoughts must either be willfully generated or indulged by a conscious mind to be sinful. The thought-action fusion experienced by those with scrupulosity makes differentiating difficult and, even when a patient recognizes that a thought may not be sinful, they are unable to convince themselves that it is not sinful. This disparity between the ability to accept concepts based on faith or inference is known as intolerance of uncertainty. While attested in other mental disorders, it is considered most prominent in patients with OCD, particularly in the "unacceptable thoughts" subtype of which scrupulosity is usually considered a part. As a result, individuals with scrupulosity feel that it is both possible and necessary to ascertain with perfect certainty the solutions to their obsessions and become greatly distressed when they discover no such certainty can exist. Excessive doubt Patients exhibit "periods of unusual and disabling confusion or doubt" surrounding their understanding of moral principles and whether an action has violated such principles. These are often triggered by experiencing a minor moral dilemma or in situations that remind them of other periods of doubt, leading to a concatenating series of thoughts that impairs rational thinking. These feelings of doubt often lead to periods of rumination, where – in an attempt to rationally resolve the anxious feeling – an individual may meticulously interrogate perceived past moral failings and obsessively meditate on philosophical or theological analyses. The centrality of this symptom has lead to the disorder's nickname as the "doubting disease". Cognitive distortion and overburdening In general, people with scrupulosity have poor insight, meaning that they cannot fully acknowledge that their behavior is irrationally motivated. Patients have difficulty interpreting normal moral frameworks and may associate unrelated actions with moral behaviors based on gut feelings. This poor awareness may be associated with an overload in mental energy expense, causing a lack of clear mental imagery which disallows for ready interpretation. This in turn leads to an inability to process a large influx of thoughts and leads to chronic worrying. Patients also interpret moral precepts with exceptional severity, even when religious language is intentionally exaggerated for effect. The misalignment of intent and interpretation by the patient leads to further disorientation. Similarly, the vast majority of those with scrupulosity feel that their symptoms interfere with their relationship with God. While virtually no religion requires perfection from their adherents, people with scrupulosity feel an excessive need for perfectionism, including outside their religious symptoms. Magical thinking is also more prominent among individuals with scrupulosity than other forms of OCD. Individuals often experience life through an additional mental "filter" which inserts moral interpretation into otherwise innocuous settings, causing the person to expend so much mental energy that relaxation and even other cognitive functions are impacted severely. This erosion of mental energy is associated with increased comorbidity with other anxiety and depressive disorders. Compulsions To mitigate the associated feelings of guilt and anxiety, individuals compulsively engage in excessive and ritualistic religious behaviors, including persistent praying, reading and rereading of religious texts, visits to confession, reassurance seeking, thought suppression, and apologizing. Instruction or absolution provided by religious leaders may create temporary relief before obsessions creep back in, but severe cases may be nearly unaffected. Individuals with scrupulosity may sometimes avoid places and contexts they believe will begin a cycle of doubt. They may also postpone attending religious services or worshiping, or may avoid them altogether. Certain religious texts may also be avoided. Avoidance behaviors may extend to other facets of life, where an individual with scrupulosity may feel they may do or say something immoral in company. These compulsive behaviors reinforce the individual's obsessions, creating a cycle. Counterintuitively, both avoidance and compulsive behaviors – including thought suppression and distraction – increase obsession frequency, leading to obsessional preoccupation. It is thought that the behaviors serve as retrieval cues for the obsessive thoughts that led to the behaviors. This amplifies feelings of doubt, which in turn increase the need for neutralizing behaviors. For example, a person anxiously uncertain if they are going to hell may obsessively seek out interpretations of their faith's infernological doctrine to alleviate fears, which only deepen feelings of doubt. Relationships to other kinds of compulsions are not unknown either. In a study among Western Christian OCD patients, those with high religiosity exhibited higher levels of handwashing than other patients and placed increased emphasis on getting hold of one's thoughts, which the researchers related to the Sermon on the Mount and similar passages in the Bible which equate thought with action. By contrast, handwashing among Jewish and Muslim patients is readily identifiable with ritual washing associated with prayer and other customs, both in Judaism and in Islam. ==Causes==

What causes scrupulosity as opposed to other manifestations of OCD is uncertain. Terror management theory (TMT) views religion as having a coping role for the inevitability of death; under this framework, scrupulosity emerges as an dysfunctional form. Individuals with scrupulosity may feel that God is present and in control, but that they are totally severed from the divine connection, impairing their ability to cope with the finality of death. Another suggestion is that scrupulosity acts as a way of seeking out security in domains where one is unable to facilitate confirmation of success, as one is with the confirmation that sins have been wiped away or that one's relationship with God is positive. Intolerance of uncertainty, a typical symptom of OCD, may distinguish typical expressions of religiosity from dysfunctional scrupulosity. While religiosity is not correlated with the development of scrupulosity, childhood trauma and "maladaptive guilt induction strategies used by parents" are. ==Diagnosis==

, there are four diagnostic tools which measure scrupulosity without measuring other OCD symptoms: the Penn Inventory of Scrupulosity (PIOS), the revised Penn Inventory of Scrupulosity (PIOS-R), the Scrupulous Thoughts and Behaviors Questionnaire (STBQ), and the Scrupulosity Inventory (SI). The PIOS and the PIOS-R are the most-widely used of these diagnostic scales, though the PIOS has been criticized as ineffective at identifying scrupulosity in non-Christians. Other more traditional approaches to diagnostics may be used as well. One example is the use of traditional OCD diagnostic tools – including the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS), Beck Depression Test, and the Beck Anxiety Inventory – with observations of religious qualities in obsessions and compulsions. Y-BOCS has been criticized in its use for scrupulosity patients since it only asks one question about religious fears. Because of this, clinicians may ask probing questions about religious manifestations of typical OCD symptoms, such as whether they have blasphemous intrusive thoughts or whether they worry excessively about divine punishment. Specific questions pertinent to the specific religion of the patient may also facilitate diagnosis. It can sometimes be difficult to tell when an action passes from normative religious practice into scrupulosity. The two may be differentiated from other normative religious rituals and avoidance in asking several questions: • Is the behavior more extreme than the patient's peers interpret the religious obligation? • Is the behavior excessively narrow or trivial? • Is the behavior impairing typical religious, family, and career functions? • Is the behavior excessively distressing to the patient or limit the patient's ability to practice their religion? Given the likelihood of religious OCD patients to have scrupulous symptoms and the general paucity of insight in scrupulosity cases, it is recommended that such patients be screened for scrupulosity. ==Treatment==

is a common treatment for scrupulosity patients. Treatment of scrupulosity includes both psychotherapeutic and psychopharmacological approaches, and best results appear to be from a combination of the two. Psychotherapy aims to confront the individual's irrational beliefs, fortify their ability to deal with uncertainty, and manage their compulsions. Selective serotonin reuptake inhibitors (SSRIs) are generally used as pharmacological treatment if symptoms are severe enough. Treatment overall, however, remains understudied. Cognitive behavioral therapy (CBT) and exposure and response prevention (ERP) both have demonstrated success treating OCD, but have had more limited success in patients with scrupulosity. In particular, standard forms of ERP have had limited success based on perceptions that even mere exposure would be morally transgressive and moral fears are difficult to falsify. Moreover, CBT's approach focuses on removing meaningfulness from intrusive thoughts, which is sometimes seen as incompatible with legitimate beliefs that thoughts have moral value. Difficulty in proving certain disordered thoughts is also a challenge, as a patient cannot be definitively convinced that they are not condemned to hell, for instance. While CBT therapy is generally considered for treating most kinds of OCD, including scrupulosity, in children and adolescents, special care must be taken to avoid "thought challenging", which is often used by minors as a compulsion to combat intrusive thoughts. Care must also be taken in CBT when externalizing scrupulosity, as patients may not accept that their issues are necessarily disordered or distinct from normative expectations religious suffering. Clinicians are often cautioned against engaging patients in theological debate, as patients are often obsessively engaged in scriptural or dogmatic study and may be more informed than the clinician. Aside from standard CBT and ERP, acceptance and commitment therapy (ACT) and other adapted CBT models have been used to treat scrupulosity, though CBT remains the most common. ERP remains highly regarded, however, with some proponents citing studies which demonstrate better outcomes and patient reports of lasting effects after sessions have terminated. Collaboration with clergy While variations of ERP exist, they may be at odds with ecclesiastical instructions given to patients. As a result, in order to best facilitate positive outcomes, clinicians must distinguish legitimate religious practice from disordered compulsion, which often requires collaboration with relevant clergy. Patients may drop out of therapy entirely if they believe the disorder is not being accurately differentiated from devotion. In some instances, clinicians may feel that religion is playing a harmful role, but this view is now discouraged. Instead, clinicians are advised to acclimatize themselves to the patient's religious sensitivities to develop rapport with patients and to better understand normative religious activities from disordered behaviors. By contrast, the integration of clergy into therapeutic efforts can fortify a patient's understanding that their condition is disordered. It is discouraged to request clergy provide dispensation for certain religious obligations, even in cases where a patient may accept it, because it provides reassurance that a patient may be unhealthily seeking out and may be an outlet for avoidance behaviors. In other cases, it may cause patients feelings of inferiority in relation to people of the same faith. While data is limited, studies show that many clergymen understand scrupulosity as distinct from spirituality, while recognizing that it is not something they are equipped to deal with personally. Less recognizant clergy, however, may unwittingly provide advice that is contrary to accepted clinical practice or attribute the patient's scrupulosity to insufficient piety. Collaboration between therapists and clergy can help mitigate reassurance behaviors in patients by helping clergymen recognize the behavior in the patient. ==Prognosis==

Prognosis for scrupulosity is generally worse than that of other obsessive–compulsive spectrum disorders. It is relatively treatment-resistant, responding less successfully overall to behavioral therapy and selective serotonin reuptake inhibitors (SSRIs), both of which are traditionally first-line treatments for OCD. Both high levels of scrupulosity and low insight in OCD patients are associated with poor treatment response. Difficulty in addressing scrupulosity in treatment is manifold, as a patient may not believe things that are considered orthodox among other coreligionists, and the difference between disorder and legitimate spiritual struggle is often unclear. Long-term, severe cases sometimes lead to "surrender", where the patient gives in to "the urge to commit the sin"; this is considered an extreme distress signal. Those with scrupulosity have a higher incidence of depression, low self-esteem, self-harm, and suicide. Those with scrupulosity are do not appear to have more severe forms of OCD overall, but they are at a higher risk of depressive and other anxious symptoms, as well as signs of obsessive–compulsive personality disorder. Symptoms may worsen with stress. ==Epidemiology==

Scrupulosity is generally considered to be a fairly common subtype of OCD. Although obsessive–compulsive disorder represents only about 1% of the general public with a lifetime rate of between 2% and 2.5%, scrupulosity cases may comprise a large subset of that group, with estimates between 5% and 33% of OCD patients exhibiting signs. Another study placed number on a scale from 0% to 93% depending on the place studied, suggesting differences in the prominence of religion culturally may affect rates. One study of Saudi Arabia and Egypt, for example, found rates of 50% and 60% of religion-based symptoms in their OCD populations, respectively. Studies in Western cultures have suggested that while 10% and 33% of people with OCD have religious symptoms, somewhere between 5% and 6% primarily exhibit symptoms of scrupulosity, making it the fifth most-common class of OCD symptoms. However, accurate quantification of the afflicted population is difficult, as people with the disorder often seek spiritual guidance instead of mental healthcare. Overall, about 18% of those with scrupulosity identify as having no religious affiliation. There is no evidence that religious people are more likely to have OCD than the general public, but those who are religious are more likely to experience scrupulosity as opposed to other subtypes of OCD. Attempts to map religious affiliation to scrupulosity have had with mixed outcomes. Several studies suggest Protestants in highly religious cultural contexts have the highest rates of scrupulosity, while a 2019 study places Catholics as having the highest incidence. Others suggest Jewish communities tend to have a higher rate of scrupulosity than other groups. A 2010 analysis found that the prevalence of religious symptoms in those with OCD varies drastically across different countries, from as low as 2% in the United Kingdom to as high as 62% in Israel. Studies of Orthodox and non-Orthodox Jewish populations found that Orthodox Jews were better able to identify scrupulosity and more likely to recommend clinical treatment than their non-Orthodox counterparts. It is possible that religions which place particular emphasis on adherence to a behavioral code may influence the categorization of obsessions as contamination-based rather than religious based. For example, Jews following kosher diets and Muslims following halal diets may have obsessions relating to the contamination of food through a religious basis rather than a medical one, which would typically be categorized under contamination OCD. Similarly, Catholic individuals with scrupulosity demonstrate marked emphasis on perfectionism than other Christian patients. Studies involving ethnic background and national origin, suggest that cultural considerations are relevant to the manifestation of symptoms. For example, a 2011 study found that contamination concerns among Turkish Muslims were higher than their Bulgarian-born counterparts, which may be attributable to the higher salience of Islam in everyday life in Turkey. In India, male OCD patients report higher levels of religious symptoms. Studies of East Asian populations suggests Chinese OCD patients exhibit higher rates of scrupulosity than Japanese patients. ==History==

Scrupulosity may be one of the earliest identified mental illnesses. The oldest text thought to contain a description of OCD is from a Buddhist text estimated to be around 2,500 years old. It describes a monk who was obsessed with sweeping the floor, often to the point of neglecting his monastic duties. During the first century AD, the ancient Greeks described scrupulosity-like state of mind they called (, ). The ancient Greek philosopher Plutarch (), himself a priest at the Temple of Apollo in Delphi, described the condition as a "mental anguish unnecessarily endured" and referred to those with it as "victims". Plutarch distinguished the condition from other forms of superstition and atheism, describing it more akin to a phobia. The earlier Greek philosopher Theophrastus () appears to have described OCD as a whole in his Characters, an outline of moral archetypes, under the title of the (), though this character is generally considered satirical. In 1691, the English Anglican bishop John Moore gave a speech concerning what he called "religious melancholy", which was a major public acknowledgement of scrupulosity as a mental illness. Religious figures such as Martin Luther, Agostino Gemelli, Ignatius of Loyola, and Alphonsus Liguori are all thought to have had scrupulosity. Scrupulous Anonymous, a Catholic Redemptorist newsletter ministering to those with scrupulosity, is published by an organization bearing Liguori's name. The French nun Thérèse of Lisieux is known to have had scrupulosity to such an extent that she experienced debilitating headaches; she compared the disorder to a painful martyrdom. In 1994, the American Psychiatric Association officially differentiated it from other forms of OCD in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. ==See also==