Scrupulosity: A cognitive–behavioral analysis and implications for treatment

• We describe the nature of scrupulosity and its association with religiosity.
• We outline a cognitive–behavioral formulation of scrupulosity.
• We discuss ways to implement exposure and response prevention for scrupulosity.

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.