What is Moral Scrupulosity OCD?

Obsessive-compulsive disorder (OCD) is defined by the presence of obsessions (intrusive and distressing thoughts, urges, doubts, or mental images) that prompt compulsions (repetitive behaviors or mental acts performed to reduce the distress those obsessions generate; American Psychiatric Association, 2022).

The lifetime prevalence of OCD is estimated at about 2.3%, although this number may be higher (Ruscio et al., 2010)When attending a 4-day intensive Exposure and Response Prevention (ERP) training for OCD hosted by the Center for Anxiety & Behavior Therapy, the facilitators emphasized we all have obsessive and compulsive tendencies. Of course, these tendencies do not become the disorder until they cause distress and interfere with functioning. More than 25% of respondents in a US sample reported experiencing obsessions and compulsions at some point in their lives, which suggests the public health burden extends beyond those who meet criteria for OCD (Ruscio et al., 2010).

The concept of “Pure O” presentations of OCD are controversial and debated in the OCD provider community. “Pure O” presentations of OCD involve someone experiencing only obsessions, not compulsions. Although I don’t completely rule out this presentation, I’m of the belief the compulsions can be covert and difficult to recognize. Throughout my experience in working with clients with OCD in multiple settings, all clients have experienced compulsive behaviors to some degree. These compulsions can include mental review, self-reassurance, or attempts to neutralize thoughts. This is relevant because moral scrupulosity compulsions include many covert, mental acts that may otherwise be overlooked. If a patient engages in treatment such as Exposure and Response Prevention (ERP) and compulsions are not identified, any exposure work would be effectively undone by a patient engaging in their compulsive behaviors.

Scrupulosity OCD is a presentation of OCD where the obsessions and compulsions focus on religious or moral concerns. This presentation has primarily been studied through a religious lens. The most widely used measure, the Penn Inventory of Scrupulosity, includes a dimension called the fear of sin (Abramowitz et al., 2002; Olatunji et al., 2007). Conceptually, moral scrupulosity mirrors the fear-of-sin dimension seen in religious scrupulosity. The fear of doing wrong is the same; without the religious context. Someone experiencing moral scrupulosity is not concerned with divine punishment, rather they are concerned that a thought, action, or even the mere possibility of either means that they are fundamentally bad person.

Because moral scrupulosity is not structured around a religious tradition, it can be missed by clinicians who look for compulsions including confession, prayer, or religious rituals. It can also go unnoticed because the symptoms resemble conscientiousness. Apologizing, volunteering, and introspection can look like human decency. Individuals with moral scrupulosity typically have well-established values. They often care intensely about behaving ethically, and hold themselves to a very high standard of moral certainty.

Conscientiousness or Moral Scrupulosity?

Abramowitz and Jacoby (2014) observed that scrupulous compulsions can be difficult to tease apart from normative religious practice, since the behavior may resemble a devoutly religious person. The same problem occurs with moral scrupulosity where apologizing, careful self-examination, and self-reflection are common prosocial behaviors. The differentiation relies on function of the behavior rather than the behavior itself.

Several indicators that the behavior is driven by OCD (versus normative religious practice) are useful:

1. The concern is ego-dystonic and driven by obsessive doubt. The person is not confirming a value, but attempting to resolve an (unanswerable) question.
2. The behavior aims at achieving certainty rather than repairing an actual harm. It is repeated because certainty is never reached.
3. The standard is absolute, and only applied to the self.
4. The behavior produces short-term relief, as any compulsive behavior does, followed by the return of obsessive doubt. This is not the settled feeling that follows genuine moral repair.
5. The behavior is time-consuming and impairing, conscientiousness is not.

Cognitive Factors

Modern cognitive models posit that intrusive thoughts are largely universal and that what distinguishes clinical obsessions is the meaning assigned to them (Rachman, 1997; Salkovskis, 1985). A few appraisal processes are relevant to moral scrupulosity:

Inflated Responsibility

Inflated responsibility is the belief that someone is crucially responsible for preventing or repairing harm, including harm that is only imagined or anticipated. It is a distinguishing feature of the cognitive model of OCD, when compared to other anxiety presentations (Salkovskis, 1985; Salkovskis et al., 2000). In moral scrupulosity, the individual believes this applies to not only their character but also any outcomes that may occur, even those out of their control. The person feels accountable for the content of their own mind. 

Moral Thought-Action Fusion

Moral thought-action fusion is the belief that merely having an unacceptable thought is equal to performing the unacceptable thought (Shafran et al., 1996). This is a second key mechanism in moral scrupulosity OCD. Experimental work indicates that this belief is more prominent in religious individuals. In one in vivo example, religious individuals judged writing and thinking about negative events as more morally wrong than non-religious participants (Berman et al., 2010). This is significant for moral scrupulosity, because those experiencing unwanted intrusions (and believe the intrusions cause the same level of harm as actually completing the corresponding action) may use them as evidence of hidden immorality.

Feared Self-Perceptions

Feared self-perceptions are a third factor, where people with greater obsessive-compulsive symptoms fear who they might secretly be. This impacts how the intrusions are interpreted: any intrusive thought is used as evidence that they are this feared self. This concept has been studied in non-clinical samples and needs further research, although a promising concept so far (Nikodijevic et al., 2015). The person doesn’t question “did I do something wrong?” but “what does it mean about it me that this intrusion occurred?”

Intolerance of Uncertainty

Intolerance of uncertainty is a core theme in any OCD presentation. It is particularly relevant to moral scrupulosity OCD because moral questions are difficult to resolve or answer with certainty. Someone who requires certainty to “confirm” their morality will never be satisfied.

Obsessional Content

Obsessions related to moral scrupulosity can present as the following:

1. Excessive guilt and an inflated sense of responsibility
2. Extreme rigidity regarding morals that are usually applied more harshly to the self than others
3. Black-and-white assessment of morality, someone is wholly good or wholly bad
4. Frequent questioning whether they have done something wrong
5. Obsessive doubt (without evidence) that someone secretly has traits inconsistent with their character
6. Perfectionism related to being a good person

Compulsive Content

Compulsions in moral scrupulosity often take the form of moral “cleansing” or reassurance seeking. Compulsions may include:

1. Prayer or excessive religious rituals or practice
2. Mental review of thoughts or actions to decide if they were immoral
3. Regular confessing or apologizing, including when no wrongdoing occurred
4. Attempts to undo a perceived wrong through excessive volunteering or compensatory good deeds

Reassurance seeking generally involves friends, family, loved ones, or religious figures. The person questions, “Am I a good person?” or “Do you think that was wrong?” When answering with reassurance, these supportive figures are providing the same short-term relief consistent with a compulsion. They are often unaware of the cycle. It is important for clinicians to be aware of these cycles as well, because patients often subtly ask for reassurance in sessions.

Emotional Impact and Barriers to Recognition

People experiencing moral scrupulosity feel intense guilt, shame, self-criticism, and low self-worth. The feared outcome is about the self, so it affects identity in a way that other OCD presentations may not. Depression is a common comorbidity.

Recognition can be difficult because individuals with moral scrupulosity believe they are genuinely immoral. As noted above, symptoms may be overlooked because they can mirror a highly conscientious person or strict religious observer. Greater OCD severity is associated with low insight and more impairment (Ruscio et al., 2010).

Buchholz and colleagues (2019) suggest that scrupulosity has been linked in prior work to poorer OCD treatment outcomes. This may be because of lack of clinician’s familiarity with the presentation and unintentional reinforcement of religious rituals by religious communities. The same dynamic can occur in secular communities, when prosocial behaviors are valued. Clinicians should ask directly about moral doubt when assessing OCD, because it is often not recognized by the patient.

Evidence-Based Treatment

Exposure and response prevention (ERP) remains the gold standard treatment for OCD. When used for moral scrupulosity OCD, ERP should be modified slightly. Exposures should target the tolerance of uncertainty, not encourage the patient to violate a value. Abramowitz and Jacoby (2014) emphasize this greatly in the religious context, and can be applied to the non-religious community as well.

In exposures, patients will sit with the possibility of having been wrong. They might write out situations where they may have done something wrong, but will never find out. They may visualize a scene where they may have acted immorally. It is important to note, exposures shouldn’t include asking the patient to behave in a way they consider to be unethical.

Response prevention involves first identifying mental review, confession, apology, and reassurance seeking. As highlighted before, patients are usually not aware they are engaging in these compulsions. After identifying the specific compulsions, the clinician will guide the patient in limiting engagement and sitting with the discomfort.

Inference-based cognitive behavioral therapy (I-CBT) is a relatively new evidence-based approach that may be helpful in situations where the patient experiences significant obsessional doubt about the self. I-CBT focuses on the reasoning processes that generate doubt.

Acceptance and commitment therapy (ACT) has also been evaluated as a treatment as an addition to ERP. In one study, although adding ACT to ERP did not improve outcomes, the focus on organizing a life based on one’s values may benefit those with moral scrupulosity OCD. The overall therapeutic goal is to help the patient to incorporate the values in their lives, not demand certainty around morality. Further research is needed on ACT as an addition to ERP.

Psychotropic medication can be beneficial for many individuals. The research on whether medication changes treatment outcomes with proper ERP is mixed. A consultation with an OCD prescribing specialist is a useful starting point.

Take Away Points

1. Moral scrupulosity is a presentation of OCD where the obsessions and compulsions are related to the fear of being a bad person. Symptoms can include a religious context or not.
2. Inflated responsibility, moral thought-action fusion, feared self perceptions, and intolerance of uncertainty are the core mechanisms of moral scrupulosity OCD.
3. Behaviors such as apologizing, introspection, self-examination, and completing good deeds can be misunderstood as typical prosocial behaviors. The function of the behavior determines whether these behaviors are compulsive. If the behavior is related to determining certainty, repeated without a resolution, and impairing, it is likely compulsive.
4. ERP should focus on tolerating uncertainty, not engaging in a genuine moral violation.
5. OCD is often chronic. Treatment should be framed as meaningful symptom reduction and improvement in functioning rather than complete extinction of symptoms.