Scrupulosity: A cognitive–behavioral analysis and implications for treatment Jonathan S. Abramowitz n , Ryan J. Jacoby University of North Carolina at Chapel Hill, Campus Box 3270 (Davie Hall), Chapel Hill, NC 27599, United States article info Article history: Received 11 September 2013 Received in revised form 29 December 2013 Accepted 30 December 2013 Available online 4 February 2014 Keywords: Scrupulosity OCD Obsessions Compulsions Religion Thought–action fusion abstract Scrupulosity involves obsessive religious doubts and fears, unwanted blasphemous thoughts and images, as well as compulsive religious rituals, reassurance seeking, and avoidance. This article provides a comprehensive review of the nature of scrupulosity, including (a) a detailed clinical description, (b) information about how to differentiate scrupulosity from normal religious practice, (c) cross cultural aspects of scrupulosity, and (d) the relationships between scrupulosity and religiosity. Next, evidence is presented in support of scrupulosity as a presentation of obsessive compulsive disorder (OCD), and a cognitive–behavioral model of scrupulosity extending current models of OCD is outlined. In this model, the influence of religion on the misinterpretation of unacceptable intrusive thoughts, the ways in which symptom content depends on one's religious identification, and the role of intolerance of uncertainty are emphasized. Finally treatment implications are discussed for applying exposure and response prevention and cognitive techniques to the specific concerns relevant to scrupulosity. & 2014 Elsevier Inc. All rights reserved. 1. Introduction More and more, the collection of signs and symptoms that we call obsessive–compulsive disorder (OCD) is becoming recognized as highly heterogeneous. Accordingly, various “mini models” of particular presentations of this problem have emerged, such as those for contamination (Rachman, 2004), checking (Rachman, 2002), hoarding (which is no longer considered a primary symp- tom of OCD; Frost & Hartl, 1996), symmetry and ordering concerns (Summerfeldt, 2004), repugnant obsessions (Rachman, 2003), relationship obsessions (Doron, Szepsenwol, Karp, & Gal, 2013), and postpartum presentations of OCD (Fairbrother & Abramowitz, 2007). These models are grounded in empirical evidence and are continually evaluated and reformulated. In many cases, they have also led to the development of treatment programs for relatively homogeneous manifestations of OCD. One such presentation that is well-known to clinicians and researchers, but has been relatively understudied and lacks such a well-articulated conceptual mini model, is scrupulosity—obsessions and compulsions having to do with religion and morality. In this article, we review the current state of knowledge of scrupulosity and apply the cognitive– behavioral framework for understanding OCD to conceptualizing the development and maintenance of this particular presentation of the problem. The application of this conceptual model to the treatment of scrupulosity is also described. 2. The nature of scrupulosity 2.1. Clinical description Scrupulosity literally means fearing sin where there is none. Common religious obsessions include recurrent doubts that one has committed sins or moral transgressions by mistake or without realizing it (e.g., “Was I cheating on the test when I gazed quickly around the room?”), intrusive sacrilegious or blasphemous thoughts and images (e.g., “The devil is helping me get through the day”), doubts that one is not faithful, moral, or pious enough (“What if I don't really love God as much as I should?”), fears that one didn't perform a religious prayer or ceremony properly (“What if my mind wandered while I was worshipping?”), and persistent fears of eternal damnation and punishment from God (“What if I'm not saved?”). Common religious compulsive rituals include excessive praying, repeating religious rituals and bible verses until they are done or said “perfectly”, seeking unnecessary reassurance from clergy or loved ones about salvation or other religious matters, and excessive or inappropriate confession. Individuals with scrupulosity often avoid situations and stimuli that trigger their obsessions and compulsions, such as places of worship, bibles and other religious icons, listening to sermons, reading Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/jocrd Journal of Obsessive-Compulsive and Related Disorders http://dx.doi.org/10.1016/j.jocrd.2013.12.007 2211-3649 & 2014 Elsevier Inc. All rights reserved. n Corresponding author. Tel.: þ1 919 843 8170; fax: þ1 919 962 2537. E-mail address: jabramowitz@unc.edu (J.S. Abramowitz). Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 140–149