It’s likely that if you suffer from scrupulosity, you may feel horror or shame at some of the terrible thoughts you have had. You may likely be determined to never tell anyone the specific content of some of your thoughts. However, did you know that those without OCD have similar types of thoughts? Yes, even thoughts that may be disturbing, terrorizing, or horrific!

My clients are always surprised when I tell them that I occasionally have intrusive thoughts, even though I do not personally struggle with OCD. Don’t worry—when I share this, I am not making some highly personal, vulnerable disclosure that constitutes an inappropriate disclosure from a therapist to her client. Nor do I feel threatened by sharing it here, because “research has revealed that 90–99% of the entire population report similar ‘intrusive’ or ‘unwanted’ thoughts from time to time (and the other 1–10% are probably fibbing).”[1] One research study examined fifteen sites in thirteen countries across six continents.[2] They found that 94 percent of people in a nonclinical (those without mental illness) population experienced at least one intrusive thought in a three-month period prior to the study.[3] The most commonly reported intrusive thoughts were doubting thoughts, while the least commonly reported were repugnant intrusive thoughts, such as blasphemous, immoral, and sexual thoughts. The doubting thoughts were the easiest to control, while the repugnant intrusive thoughts were among the most difficult to control.

My clients are often surprised when I tell them that the types of intrusive thoughts I have are just as disturbing as the types of thoughts with which they struggle. At times, I also have morbid, violent, self-harm, or angry thoughts; sexual thoughts; blasphemous thoughts; dishonest thoughts; and the like. In a news article, the author of a large multinational study made this observation:

Confirming that these thoughts are extremely common helps us reassure patients who may think that they are very different from everybody else.

For instance, most people who have an intrusive thought about jumping off a balcony or a metro platform would tell themselves that it’s a strange or silly thing to think, whereas a person with OCD may worry that the thought means they’re suicidal. OCD patients experience these thoughts more often and are more upset by them, but the thoughts themselves seem to be indistinguishable from those occurring in the general population.[4]

A land mark study published in 1978 examined this very concept. [5] Researchers asked people without OCD if they ever had thoughts or impulses that were intrusive and unacceptable. Eighty percent of these people reported that they experienced those types of thoughts at least once a week. Then the researchers transcribed the “unacceptable thoughts” and had them rated by experts who also had a list of nonclinical intrusive thoughts to see if the clinical obsessions were discernible by content alone. The experts could not tell which obsessions belonged to those with clinical OCD.

One research study examined the responses of 293 nonclinical (without OCD) students to questions about obsessive intrusive thoughts.[6] The researchers endorsed the content of fifty-two items. Some of these items included running the car off the road, swerving into traffic, slitting one’s wrist or throat, jumping off a high place, jumping off (or in front of) a train or car, fatally pushing a friend or stranger, insulting authority, choking a family member, stabbing a family member, swearing in public, having sex with an unacceptable person, having sex with an authority figure, exposing oneself in public, committing acts against one’s sexual preference, and imagining authority figures naked. Might some of these seem familiar to you? Hopefully, reviewing the content of intrusive thoughts from those without OCD is comforting to those of you with OCD. It might “seem like no one else thinks about terrible, dirty, or immoral things, and that therefore you’re abnormal, dangerous, perverted, or immoral. But they do and you aren’t.”[7] Everyone has them at least occasionally.

The Difference between Those without OCD and Those with OCD

If almost everyone is having the same types of autogenous, intrusive thoughts, then what is the difference between those without OCD and those with OCD? The obsessions of OCD tend to occur more often and last longer and are more distressing than normal intrusive thoughts are to those without OCD. In addition, those with OCD tend to give intrusive thoughts more meaning and importance than do other people. As such, they may be less willing or able to tolerate them and put more effort into trying to suppress them.[8]

For example, those without OCD tend to react to intrusive thoughts in the following four ways: (1) They check for evidence. (2) They shift their attention from the thought to something else. (3) They try to analyze why the thought occurred. (4) They may discuss the thought with other people.[9]

In contrast, those with OCD are more likely to react to these intrusive thoughts in two other ways: (1) The thought triggers anxiety. The sufferers may worry about why they had the thought and what it might mean about their character, such as if it makes them corrupt or perverted. They worry that the thought may cause something bad to happen or has contaminated them in some way.(2) They punish themselves for thinking the thought, giving themselves consequences, either physical or mental, based on what they think they deserve. [10]

Since those of you with OCD are experiencing so much anxiety, the thought does not feel irrelevant to you, not in the least—it feels very serious, and in scrupulosity it feels eternally soul-defining. Thus it is much harder to ignore. So instead of noticing the thought and deciding that it is not in line with your values, then shifting your attention to the next thought streaming through your consciousness, your anxiety triggers an alarm system that screams loudly to you that something is wrong, very wrong! But unfortunately, it is a false alarm, and your concern leads to an increase in the intrusion.[11] There is a “difference between having a thought and buying a thought.”[12] The more you believe the thought is meaningful, or that you are responsible for the thought in some way, the more frequent the thought becomes.[13] In this sense, it is anxiety that is deciding which thoughts you are paying attention to, rather than you getting to decide based on your personality, values, goals, dreams, and ideals.

Researchers have posited three broad reasons why those with OCD respond to intrusive thoughts with pathological anxiety. First, the person’s beliefs may be exaggerated, overestimating the potential threat of the thought.[14] One Islamic scholar taught the following:

O one afflicted with the sickness of scruples! Do you know what your scruples resemble? A calamity! The more importance they are given, the more they grow. If you give them no importance, they die away. If you see them as big, they grow bigger. If you see them as small, they grow smaller. If you fear them, they swell and make you ill. If you do not fear them, they are light and remain hidden. If you do not know their true nature, they persist and become established. While if you do know them and recognize them, they disappear.[15]

Second, instead of the problem lying with the thoughts, it is possible that the emotions of those with OCD may be stronger and more persistent for the same thought than it is for someone without OCD. Third, people with OCD may have less ability to make the mental shift away from a disturbing thought. All three of these proposed explanations are relevant and interact with the others.[16]

Varying Thought Processes

Although intrusive thoughts occur for most people, the quality of the thought process around those intrusive thoughts varies significantly. The nature of thoughts can be conceptualized on a continuum, beginning with rational thought, worry, and rumination, then moving along the continuum to obsession, overvalued ideas, and finally to delusional thought.

Rational thought

A person responding to an intrusive thought in a rational way stays present-minded and thinks through the situation with reason and understanding, using conscious thought to solve the problem in a way that makes sense. (Other people will also understand the logic of the ideas.) The individual’s insight into the thought process is about 95 to 100 percent.[17] In Dialectical Behavior Therapy this is called the Reasonable Mind, and it is cool, rational, and task focused. A person in this Reasonable Mind state is ruled by facts, reason, logic, and pragmatics.[18]

Worry

When a person responds to an intrusive thought with worry, he or she experiences “mental distress or agitation resulting from concern usually for something impending or anticipated.”[19] Although somewhat distressing, worry is normal and controllable.[20] Worry is often triggered by uncertainty, and it is often associated with anxiety, although the two are not synonymous: anxiety is more intense, tends to be vague, and has more physical symptoms in the body. Worry and anxiety both tend to be future-oriented.

Rumination

Rumination is more intense than worrisome thoughts. Some researchers have defined rumination as a “detrimental psychological process characterized by perseverative thinking around negative content that generates emotional discomfort. . . . Rumination refers to both the thought process (i.e., excessive thinking) as well as thought content (i.e., negative).”[21] Rumination is preoccupying and interferes with your ability to focus on other things. Unlike obsessions that are involuntary and unwanted (something that happens to you), rumination is consciously done by the person (something that you do). Rumination is a mental compulsion. Most people fail to recognize mental acts as compulsive, yet a compulsion is any act (physical or mental) done to try to neutralize one’s anxiety.

Rumination involves an inordinate amount of time. Unlike obsessions, which are usually disturbing to one suffering with OCD, ruminative topics can be interesting and even feel indulgent at times. One may spend hours upon hours worrying about, analyzing, replaying, trying to understand, or trying to clarify an idea or concern. Again, unlike obsessions, in which a person can’t stop thinking about something, in rumination a person could stop thinking about it but won’t. The person actually wants to think about it and so refuses to let go of it. One client, a married woman in her sixties, described rumination of a fearful thought as “ultra-to-the ridiculous, torturing myself with it.”

One reason my clients ruminate is because they hold tenaciously to the belief that by thinking about their concern long enough they can make sense of it. That is a faulty belief. Please know that rumination is not an effective problem-solving strategy. None of my clients have ever solved their scrupulous fears with rumination—not one!

One client, a married man in his thirties with two children, shared this about the role of rumination in his scrupulosity:

Rumination was one of the most difficult parts of my scrupulosity and OCD. I would ruminate on fears and doubts until I would burst out into massive bouts of confessions to my wife. After the confessions the ruminating got worse because I would then ruminate on whether I covered everything in my confessions. I couldn’t even have a normal conversation with my wife because I was constantly ruminating on uncertainties. This went on for years. Rumination is like an app on a phone that never closes, always running in the background leaving little room for anything else to operate. When there was any open mental space, my mind would go right back to the rumination app. It was an energy suck, an emotional drain. I had to learn how to kill that rumination app. Today there are still things that bother me; I still have doubts and fears. But instead of letting rumination consume me and destroy my relationships, I have learned to implement therapeutic tools and switch it off in a matter of minutes or hours depending on the situation.

Some rumination may be due to a phenomenon in OCD called not just right experiences. “A not just right experience (NJRE) is an uncomfortable sensation that signals and represents a perceived mismatch between the state of the world or of one’s own performance and the individual’s accepted standards.”[22] Obsessive-compulsive features that tended to show the strongest correlations with NJREs were checking, ordering, and doubting.

Becoming aware of rumination is important. Recent researchers have found that rumination about an unwanted intrusive thought is involved in maintaining the urge to act on such thoughts.[23]

How is rumination different from everyday worry? Researchers have clarified that although rumination and worry are both forms of perseverative thought (i.e., fixating on a thought), rumination focuses on the ongoing processing of negative content, whereas worry focuses on the ongoing processing of uncertainty. Rumination content tends to be more focused in the past or present, while worry focuses more on the future. Rumination content may also coalesce around themes of loss, whereas worry coalesces around themes of anticipated threat.[24] In scrupulosity, much of what sufferers engage in is rumination.

Obsessions

Although I have already formally defined obsessions in chapter 1, it would be useful here to reinforce the idea that obsessions are negative forbidden thoughts that trigger anxiety and aren’t within conscious control.[25] An obsession may be triggered by an intrusive thought that the brain gets stuck looping again and again and again. Obsessions are generally disturbing to people, and they will go to great lengths to avoid or neutralize the anxiety the obsessional thoughts create. It is said that obsessions are “caused by catastrophic misinterpretation and appraisals that unwanted intrusive thoughts have some meaning.”[26]

Overvalued ideation

Overvalued ideation is “a false belief that is maintained despite strong evidence that it is untrue.” This goes beyond the bounds of reason. When others describe such beliefs as excessive, the person struggling with overvalued ideation can recognize that assessment makes sense yet cannot do so independently. Overvalued ideation is similar to belief in a delusion (discussed below), but the thoughts are more plausible and not maintained to the same degree.[27] For those with scrupulosity, poor insight has been associated with OCD severity.[28]

Delusion

Those with delusional beliefs have zero insight.[29] Delusions are less plausible than overvalued ideation, and their onset seem less reasonable. People with delusions tend to be less preoccupied, less concerned with what might modify their thoughts, and less concerned with others’ perceptions.[30]

Scrupulosity

When anxiety and these varying thought processes (e.g., worry, rumination, and obsessions) work their way into a person’s religious, spiritual, or moral world, this is known as scrupulosity. In scrupulosity, OCD is “characterized by religious or moral core fears.”[31] One author offered this definition of a scruple: “a scruple is a futile effort to prove with certitude that one has not sinned [or acted immorally] in a doubtful incident.”[32]

Religious and moral obsessions include obsessions concerned with taboo content, such as religion, sex, and aggression or harm. They may include unwanted blasphemous thoughts against God. They can also include unholy ideas or images. You might have fears or doubts about your discipleship in your chosen religious faith. You may be excessively concerned if you have committed a sin or broken a commandment. You may worry about disappointing God or losing your salvation. You may have fears about general morals, such as not cheating or lying or being a “good person,” even though you do not subscribe to any particular religious tradition. You may then enact compulsions, such as praying excessively, confessing repeatedly, or seeking reassurance.

Scrupulosity can be seen in people from all religious traditions, as well as in people who are nonreligious but whose fears, obsessions, and compulsions nevertheless have religious or moral content, such as concerns about lying, cheating, stealing, causing damage or harm, being wasteful, or being guilty of indulgence. One study found that almost one in five scrupulous study participants claimed no religious affiliation, [33] while another study found that 24 percent of its study participants with scrupulosity reported having no religious affiliation. This is called secular moral scrupulosity,[34] or, to one author, moralosity.[35]

Are my scrupulous, intrusive thoughts caused by Satan? The relationship between OCD and religion has been a topic of interest for many centuries. An archaic definition of the word obsession is to be besieged by the devil or an evil spirit from without.[36] One client described his struggle in precisely these terms:

I had been in what felt like a scrupulosity crisis for some time and was starting to become seriously fatigued with trying to control my mind. I can remember thinking to myself, “Well, he won,” referencing the devil’s victory over my mind. My thinking at the time was that my battle with OCD and scrupulosity was actually a fight with the adversary. I seriously thought I was being possessed with a devil, as I had not yet been diagnosed. I was not suicidal, but I seriously wanted to give up. Gratefully, I did not give up and help came as I endured. Remarkable miracles followed.

So, yes, it is common for those suffering with scrupulosity (or their family members) to wonder if their scrupulosity is the manifestation of evil in their life. They may wonder if Satan or other demons have caused their OCD or put the intrusive thoughts in their mind. Or they may wonder if evil is more subtly influencing them and they are knowingly choosing to follow evil when they “listen to” an intrusive thought or perform a compulsion. One person remarked, “I believed that in some cases the thoughts must come from Satan (the really bad ones), but regardless of my agency in the matter, I felt like I was responsible and worthless."

One client, a married woman in her thirties, shared the following: “My loving husband unknowingly caused more pain when he tried to help me by saying that my intrusive thoughts were just Satan trying to tempt me. I was just having ‘bad thoughts.’ With that I felt like there was no escape. Satan must be next to me all day long, in my head, and I couldn’t escape him. Why was God allowing Satan to torture me? I pleaded with God to help me resist ‘temptation.’ But my bad thoughts were always just around the corner.”

This was the main concern for another client I worked with. I asked him if he thought his OCD was Satan. He answered, “Over the years of having the thoughts ‘these are Satan,’ it all became real for me. It’s hard to make the distinction.” He had come to believe that his OCD thoughts were Satan and that if he listened to the thought in any way that he was following Satan and was guilty of sin. He asked me, “If I did have the thought and agreed with it, does that mean I made a deal with the devil?” Logically he could get to the point where he knew these ideas were not true: “I know it is irrational, but it still feels so real.” But when his anxiety triggered, it was his truth—he was immediately drawn into his stuck-ness with Satan. This discussion led him to ask me the question, “Am I bad?”

Satan is not within the OCD. OCD is a mental illness. When mental health professionals treat a person with OCD using gold-standard treatments for OCD, the condition often improves. If Satan did cause scrupulosity, then religious worship activities attended to with great faith, such as deliverance prayers, fasting, or temple attendance, would undeniably drive out the evil influence and the symptoms of scrupulosity in the person would improve. More dramatic religious interventions, such as an exorcism, would work to deliver the sufferer of scrupulosity as well.

Be advised, however, that the adversary can get involved in your scrupulosity from without. One psychologist explained, “OCD is like a surfboard and Satan is riding on the back of the surfboard. And so, OCD might say: ‘Oh no, you’ve committed the unpardonable sin.’ And then Satan says: ‘Oh, see, you’re a terrible Christian and no one would ever accept you or love you.’”[37] Satan may not be in the OCD, but he can use it to exploit his purposes. If you are struggling with scrupulosity, he will delight in playing your affliction and vulnerabilities against you. He can cause you to become discouraged, entice you to give up hope, and convince you that healing is not possible. In that way he can keep you trapped in scrupulosity. Yet, Satan is a liar! The Bible teaches that “[the devil] . . . was a murderer from the beginning, and abode not in the truth, because there is no truth in him. When he speaketh a lie, he speaketh of his own: for he is a liar, and the father of it.”[38] Remember also that Jesus Christ teaches, “These things I have spoken unto you, that in me ye might have peace. In the world ye shall have tribulation: but be of good cheer; I have overcome the world.”[39] OCD is a difficult struggle, and God has provided the knowledge to treat OCD effectively.

Notes

[1] Abramowitz, J. S. (2018). Getting Over OCD: A 10-step work book for taking back your life (2nd ed.).Guilford Press, 67; emphasis in original.

[2] The study sites were located in Africa (Makeni, Sierra Leone), Asia (Herzliya, Israel; Hong Kong; Ankara, Turkey; and Tehran, Iran), Australia (Melbourne), Europe (Chambéry, France; Firenze/Padova, Italy; Thessaloniki, Greece; and Valencia, Spain), North America (Binghamton and Chapel Hill, the United States; Fredericton and Montreal, Canada), and South America (Buenos Aires, Argentina).

[3] A. S. Radomsky et al. (2014). Part 1—You can run but you can’t hide: Intrusive thoughts on six continents. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 269–279.

[4] Concordia University. (2014, April 8). The surprising truth about obsessive-compulsive thinking [Press release]; emphasis added. https://www.sciencedaily.com/releases/2014/04/140408122137.htm

[5] Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16(4), 233–248. https://doi.org/10.1016/0005-7967(78)90022-0

[6] Purdon, C., & Clark, D. A. (1993). Obsessive intrusive thoughts in nonclinical subjects. Part I. Content and relation with depressive, anxious and obsessional symptoms. Behaviour Research and Therapy, 31(8), 713–720. https://doi.org/10.1016/0005-7967(93)90001-b

[7] Abramowitz, 2018. Getting Over OCD, 67.

[8] Abramowitz, 2018. Getting Over OCD, 68.

[9] Summers, J. S., Sinnott-Armstrong, W. (2019). Clean hands? Philosophical lessons from scrupulosity. Oxford University Press, 32–33.

[10] Summers & Sinnott-Armstrong, 2019. Clean hands?, 32–33.

[11] Abramowitz, J. S. (2008). Obsessive-compulsive disorder. In W. E. Craignhead, D. J. Miklowitz, L. W. Craighead (Eds.), Psychopathology: History, diagnosis, and empirical foundations (pp.159–197).John Wiley Sons.

[12] Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance and commitment therapy skills-training manual for therapists. New Harbinger Publications, 65.

[13] Moudling, R., Coles M. E., Abramowitz, J. S., etal.(2014). Part 2. They scare because we care: The relationship between obsessive intrusive thoughts and appraisals and control strategies across 15 cities. Journal of Obsessive-Compulsive and Related Disorders 3, 280–291. https://doi.org/10.1016/j.jocrd.2014.02.006]

[14] Summers & Sinnott-Armstrong, 2019. Clean hands?, 34.

[15] Nursi, B. S. (1998). The words. Sozler Publications, 281. http://www.erisale.com/?locale=en&bookId=201&pageNo=281#content.en.201.28

[16] Summers & Sinnott-Armstrong, 2019. Clean hands?, 34.

[17] Shapiro, L. J. (2015). Understanding OCD: Skills to control the conscience and outsmart obsessive compulsive disorder. Praeger, 42.

[18] Linehan, M. M. (2015). DBT skills training handouts and worksheets (2nd ed.). The Guilford Press, 50.

[19] Merriam-Webster. (n.d.). Worry. In Merriam-Webster.com Dictionary. https://www.merriam-webster.com/dictionary/worry

[20] Shapiro, 2015. Understanding OCD, 42.

[21] Sansone, R. A., Sansone, L.A. (2012). Rumination: relationships with physical health. Innovations in Clinical Neuroscience, 9 (2), 29–34.

[22] Mancini, F., Gangemi, A., Perdighe, C., etal.(2008). Not just right experience: Is it influenced by feelings of guilt? Journal of Behavior Therapy and Experimental Psychiatry, 39, 163.

[23] Wahl, K., vanden Hout, M., Lieb, R.(2019). Rumination on unwanted intrusive thoughts affects the urge to neutralize in nonclinical individuals. Journal of Obsessive-Compulsive and Related Disorders, 20, 4–12. http://doi.org/10.1016/j.jocrd.2018.02.002. Kollárik, M., van den Hout, M., Heinzel, C. V., et al. (2020). Effects of rumination on unwanted intrusive thoughts: A replication and extension. Journal of Experimental Psychopathology. https://doi.org/10.1177/2043808720912583.

[24] Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives in Psychological Science, 400–424.

[25] Shapiro, 2015. Understanding OCD, 42.

[26] Shapiro, L. J. (2020). Obsessive compulsive disorder: Elements, history, treatments, and research. Praeger, 102.

[27] Mullen, R., & Linscott, R. J. (2010). A comparison of delusions and overvalued ideas. The Journal of Nervous and Mental Disease, 198(1), 35–38. https://doi.org/10.1097/NMD.0b013e3181c818b2

[28] Siev, J., Rasmussen, J., Sullivan, A. D. W., & Wilhelm, S. (2021). Clinical features of scrupulosity: Associated symptoms and comorbidity. Journal of Clinical Psychology, 77(1), 173–188. https://doi.org/10.1002/jclp.23019

[29] Shapiro, 2020. Obsessive compulsive disorder, 162.

[30] Mullen & Linscott, 2010. A comparison of delusions and overvalued ideas, 35–38.

[31] Sievetal.,2021.Clinicalfeaturesofscrupulosity,173]

[32] O’Flaherty, V.M. (1973). Therapy for scrupulosity. In R.M. Jurievich (Ed.), Direct psychotherapy: Twenty-eight American originals (pp.221–243). Miami University Press, 229.

[33] Buchholz, J. L., Abramowitz, J. S., Reimann, B. C., et al. (2019). Scrupulosity, religious affiliation and symptom presentation in obsessive compulsive disorder. Behavioural and Cognitive Psychotherapy, 47(4), 478–492.

[34] Siev et al.,2021. Clinical features of scrupulosity, 184.

[35] Shapiro, 2015. Understanding OCD, 79.

[36] Wordnik. (n.d.). Obsession, archaic. In Wordnik. Retrieved March 22, 2022, from https://www.wordnik.com/words/obsession

[37] Witzig, T. F., Jr. International OCD Foundation.(2021, May 11). Scrupulosity: Over coming religious obsessions and compulsions [Video]. YouTube, 31:57 .https://www.youtube.com/watch?v=4gE6D2Ra2Yc.

[38] John 8:44.

[39] John 16:33.