Scrupulosity: Symptoms, causes, diagnosis, and treatment

Reviewed by Brooks Baer, LCPC, CMHP

Written by

therapist.com team

Last updated: 04/25/2025

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What is scrupulosity?

Scrupulosity (also called religious scrupulosity, scrupulous OCD, or religious OCD) is a relatively common but lesser-known subtype of obsessive-compulsive disorder (OCD).¹ It’s marked by extreme feelings of guilt and unwanted, intrusive thoughts about moral or religious concerns.

People with scrupulosity perform certain behaviors or mental rituals to prevent the bad outcomes they fear or to reduce their anxiety.²

The terminology around this condition varies in clinical and research settings.³ Some studies differentiate between “religious OCD” (focusing on the religious elements) and “secular moral scrupulosity” (focusing on non-religious moral concerns). There is currently no consensus on these definitions and the term scrupulosity can refer to either.

Is scrupulosity a mental illness?

Scrupulosity is not classified as a standalone mental disorder in the “Diagnostic and Statistical Manual of Mental Disorders” (DSM-5).⁴ However, it does recognize that people with OCD often focus on themes of morality and religious obsession.

What separates scrupulosity from normal religious devotion or strong moral values is how it affects daily life. When moral or religious thoughts and rituals disrupt normal activities, cause substantial emotional distress, or feel impossible to control, it could be a sign of something deeper.

Scrupulosity symptoms

How scrupulosity presents can vary significantly across different cultures and religious traditions.⁵ Cultural context is important to remember when discussing it. What might be considered typical practice in one faith community could be viewed as excessive in another.

Common symptoms

Researchers have developed tools like the Penn Inventory of Scrupulosity (PIOS) to better understand and measure how scrupulosity presents.

The PIOS identifies several symptoms including:⁶

• Intense fear of divine punishment
• Persistent worry that you aren’t spiritually acceptable
• Fixating on avoiding immoral thoughts
• Recurring fears about having inappropriate sexual thoughts
• Anxiety about unknowingly committing immoral acts
• Overwhelming, disproportionate feelings of guilt

The PIOS has proven valuable in clinical settings, though research suggests its effectiveness may vary depending on a person’s religious background.⁷ Some studies suggest it could be more sensitive in identifying scrupulosity symptoms in Christian patients compared to those of other faiths or non-religious people.

Scrupulosity examples

Just like in other presentations of OCD, people with scrupulosity may develop patterns of compulsive behaviors and avoidance to manage their anxiety.⁸

Common compulsions can include:

• Carefully writing out prayers to make sure they’re “correctly” performed
• Seeking excessive reassurance from religious leaders, family members, or friends
• Engaging in frequent or unnecessary confession
• Doing complex cleansing or purification rituals
• Repeating prayers excessively or in specific patterns
• Mentally reciting religious passages to “cancel out” certain thoughts
• Creating mental agreements or bargains
• Constantly monitoring your level of faith or moral purity
• Going out of your way to self-sacrifice beyond what’s expected
• Viewing religious services as mandatory obligations

Avoidance patterns could include:

• Staying away from religious gatherings due to fear of making mistakes
• Avoiding reading religious texts that might trigger obsessive thoughts
• Withdrawing from situations where moral decisions might be required

Versions of many these behaviors are expected in some religious practices. But the behaviors become problematic when they consume excessive time, cause significant distress, or interfere with daily functioning and relationships.

If you recognize these symptoms in yourself or a loved one, it’s important to reach out to a mental health professional. They can provide proper assessment and develop a treatment plan tailored to your needs.

Scrupulosity causes

The exact cause of scrupulosity, like other forms of OCD, remains unclear. ⁹ Most experts believe it results from a combination of factors rather than a single cause.¹⁰

Biological factors

OCD involves several brain regions that help regulate thoughts, emotions, error detection, and behavior planning. People with OCD often show differences in how these brain regions function.

Medications that affect serotonin levels are often used to help manage OCD symptoms. But while certain neurotransmitters do play a role in OCD, they’re part of a larger, more complex picture.

OCD may be partially genetic.¹¹ Children who have a parent with OCD have higher odds of developing the condition themselves. However, it could be that family environments play a role in shaping beliefs and behaviors that contribute to OCD.

Environmental factors

While genetics appears to play a stronger role than environment in OCD development, cultural and social factors can influence how OCD presents.

The specific content of obsessions differs across various cultural, ethnic, and religious groups. Both religious affiliation and broader social environments seem to shape how symptoms manifest.¹²

Obsessions may also shift in response to global events.¹³ For example, if someone experiences an impactful event like the COVID-19 pandemic, they’re more likely to have obsessions that center on it.

Scrupulosity diagnosis and treatment

Mental health professionals typically use specialized questionnaires alongside clinical interviews to distinguish between healthy religious practice and OCD symptoms. Several assessment tools have been developed to measure scrupulosity, including:¹⁴

• The Penn Inventory of Scrupulosity (PIOS)
• Scrupulous Thoughts and Behaviors Questionnaire (STBQ)
• Scrupulosity Inventory (SI)

While these tools are helpful for professionals, they’re not designed for self-diagnosis. If you have concerns about your mental health, it’s always best to speak with a trained mental health professional. They can help you determine the source of overwhelming feelings and develop a treatment plan.

Treatment approaches

Scrupulosity treatment presents unique challenges, as therapists must navigate the complex intersection between mental health and religious or moral beliefs.

Cognitive behavioral therapy (CBT) is the most researched and effective approach for treatment of scrupulosity.¹⁵ CBT helps patients recognize distorted thought patterns and gradually confront fears without engaging in compulsive behaviors. A specialized therapy technique called exposure and response prevention (ERP) is also particularly effective, though it requires careful implementation.

Other possible treatment approaches include:

• Acceptance and commitment therapy (ACT)
• Religiously-integrated cognitive behavioral therapy (RCBT)
• The cognitive psychoeducation 4T model

Scrupulosity appears differently across religious and cultural contexts, so it’s important that treatment takes a personalized approach. In some cases, religious leaders have been included in the treatment process when appropriate.

Treatment may also benefit from incorporating a person’s religious or spiritual values. For example, one small study involving Muslim patients explored integrating Islamic spiritual concepts like acceptance (rida) and patience (sabr) into therapy with positive results.¹⁶

Treatment challenges

One factor that can complicate treatment is mental health professionals’ lack of specific knowledge of their clients’ religious traditions.¹⁷ On the other hand, religious authorities may not have the specific training required to recognize symptoms of a mental health condition.

Additionally, people with scrupulosity often have limited insight into the nature of their condition.¹⁸ They may also have higher chances of experiencing co-occurring conditions like depression.

Despite these challenges, with proper assessment and treatment many people see improvements in their symptoms. Visit our directory to find therapists who specialize in OCD treatment. You can also filter directory results by faith-based specialties to find professionals who align with your specific religious background.