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It’s Not Just You

“It’s Not Just You” is a column written by mental health journalist Sian Ferguson, dedicated to exploring the lesser-known, under-discussed symptoms of mental illness.

Whether it’s constant daydreaming, obsessive showering, or concentration problems, Sian knows firsthand the power of hearing, “Hey, it’s not just you.” While you might be familiar with your run-of-the-mill sadness or anxiety, there’s so much more to mental health than that — so let’s talk about it!

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When my therapist first suggested I could have obsessive-compulsive disorder (OCD), I felt a lot of things.

Mostly, I felt relieved. 

But I also felt scared. In my experience, OCD is one of the most widely misunderstood mental illnesses — everybody thinks they know what it is, but few people actually do.

Most people associate OCD with frequent hand washing and excessive tidiness, but that’s not what it is.

Some people with OCD are incredibly concerned with hygiene, but many people aren’t. Like many others, I worried that talking about my OCD would be met with a dismissal — but you’re not obsessively tidy! — instead of understanding, even by people whose intentions were good.

As the name suggests, OCD involves obsessions, which are intrusive, unwanted, persistent thoughts. It also involves compulsions, which are the mental or physical practices used to reduce distress around those thoughts. 

Most of us have intrusive, weird thoughts from time to time. We may get to work and think, “Hey, what if I left the gas stove on?” The problem is when we give inflated meaning to these thoughts. 

We might return to the thought again and again: What if I left the gas stove on? What if I left the gas stove on? What if I left the gas stove on? 

The thoughts then become very distressing to us, so much so that we pick up certain compulsions or change our day-to-day routine to avoid those thoughts.

To someone with OCD, checking the gas stove 10 times each morning might be a compulsion intended to reduce those stressful thoughts, while others might have a prayer they repeat to themselves to cope with the anxiety. 

At the heart of OCD is fear or uncertainty, though, so it’s by no means limited to germs or burning down your home.

One way OCD can take form is scrupulosity, often referred to as ‘religious OCD’ or ‘moral OCD.’

“Scrupulosity is an OCD theme in which a person is overly concerned with the fear that they are doing something that goes against their religious beliefs or is immoral,” says Stephanie Woodrow, a counselor who specializes in treating OCD.

Let’s say you’re sitting in church and a blasphemous thought crosses your mind. Most religious people will feel bad, but then move on from that thought.

People with scrupulosity, however, will struggle to let that thought go. 

They’ll feel racked with guilt because the thought crossed their mind, and they might worry about offending God. They’ll spend hours trying to ‘make up’ for this by confessing, praying, and reading religious texts. These compulsions or rituals are aimed at reducing their distress. 

This means that religion is fraught with anxiety for them, and they’ll struggle to really enjoy religious services or practices. 

The obsessions (or persistent, intrusive thoughts) when it comes to scrupulosity can include worrying about:

  • offending God
  • committing a sin
  • praying incorrectly
  • misinterpreting religious teachings
  • going to the “wrong” place of worship
  • participating in certain religious practices “incorrectly” (e.g. a Catholic person might worry about not crossing themselves correctly, or a Jewish person might worry about not wearing the Tefillin perfectly in the middle of their forehead)

The compulsions (or rituals) could include:

  • excessive praying
  • frequent confessing
  • seeking reassurance from religious leaders
  • avoiding situations where immoral acts might happen

Of course, many religious people do worry about some of the above issues to an extent. For example, if you believe in hell, chances are you’ve worried about going there at least once.

So, I asked Woodrow, what’s the difference between non-pathological religious concerns and actual OCD?

“The key is that people with [scrupulosity] do not enjoy any aspect of their faith/religion because they are fearful all the time,” she explains. “If someone is annoyed by something or is worried about getting in trouble for skipping out on something, they may not love their religious practices, but they aren’t terrified of doing it wrong.”

Scrupulosity isn’t just limited to the religious: You can have moral scrupulosity, too. 

“When someone has moral scrupulosity, they might be worried about not treating people equally, lying, or having bad motives for doing something,” Woodrow explains. 

Some symptoms of moral scrupulosity include worrying about:

  • lying, even if unintentionally (which could include being afraid of lying by omission or accidentally misleading people)
  • unconsciously discriminating against people
  • acting ethically out of self-interest, instead of being motivated by helping others
  • whether the ethical choices you make are truly better for the greater good
  • whether you’re truly a “good” person or not

The rituals relating to moral scrupulosity could look like:

  • doing altruistic things to “prove” to yourself that you’re a good person
  • oversharing or repeating information so that you don’t accidentally lie to people
  • debating ethics for hours in your head
  • refusing to make decisions because you can’t figure out the “best” decision
  • trying to do “good” things to make up for the “bad” things you’ve done

If you’re familiar with Chidi from “The Good Place,” you’ll know what I mean.

Chidi, an ethics professor, is obsessed with weighing the ethics of things — so much so that he struggles to function well, ruins his relationships with others, and gets frequent stomachaches (a common symptom of anxiety!). 

While I definitely can’t diagnose a fictional character, Chidi is pretty much what moral OCD can look like.

Of course, the problem with addressing scrupulosity is that few people actually know it exists.

Being concerned about ethical or religious issues doesn’t sound bad to everyone. This, coupled with the fact that OCD is often misrepresented and misunderstood, means that people don’t always know what signs to look out for or where to turn for help. 

“In my experience, it takes a while for them to realize that what they are experiencing is too much and unnecessary,” Michael Twohig, a psychology professor at Utah State University, tells Healthline.

“It is common for them to think this is part of being faithful,” he says. “Someone from the outside will usually step in and say this is too much. It can be very helpful if that person is trusted or a religious leader.”

Fortunately, with the right support, scrupulosity can be treated. 

Often, OCD is treated by cognitive behavioral therapy (CBT), specifically exposure and response prevention (ERP). 

ERP often involves confronting your obsessive thoughts without engaging in compulsive behavior or rituals. So, if you believe God will hate you if you don’t pray every night, you might intentionally skip one night of prayers and manage your feelings around it.

Another form of therapy for OCD is acceptance and commitment therapy (ACT), a form of CBT that involves acceptance and mindfulness techniques.

Twohig, who has extensive expertise on ACT for treating OCD, recently worked on a study that showed that ACT is as effective as traditional CBT for treating OCD. 

Another hurdle for people with OCD is that they often fear treatment for scrupulosity will push them away from their faith, according to Twohig. Someone might fear that their therapist will discourage them from praying, going to religious gatherings, or believing in God. 

But this isn’t the case. 

The treatment is meant to focus on treating the disorder of OCD — it’s not about trying to change your faith or beliefs.

You can maintain your religion or beliefs while treating your OCD.

In fact, treatment might help you enjoy your religion more. “Studies have shown that after completing treatment, people with religious scrupulosity actually enjoy their faith more than prior to treatment,” Woodrow says. 

Twohig agrees. He worked on a 2013 study that looked at the religious beliefs of people who were treated for scrupulosity. After treatment, they found that scrupulosity decreased but religiosity did not — in other words, they were able to maintain their faith. 

“I usually say that our goal as therapists is to help the client do what is most important to them,” Twohig says. “If religion is important to them, we want to help the client make religion more meaningful.”

Your treatment plan might involve talking to religious leaders, who can help you form a healthier relationship with your faith. 

“There are a few members of the clergy who are also OCD therapists and have presented often on the balance between doing what they ‘should’ do because of religion as opposed to what OCD says a person should do,” Woodrow says. “They all are in agreement that no religious leader ever considers [scrupulosity] rituals to be good or helpful.”

The great news is that treatment for any and all forms of OCD is possible. The bad news? It’s hard to treat something unless we recognize that it exists. 

The symptoms of mental illness can show up in so many unexpected and surprising ways, so much so that we can experience a great deal of distress before ever connecting it to our mental health.

This is one of the many reasons why we should continue to talk about mental health, our symptoms, and therapy — even and especially if our struggles interfere with our ability to pursue what’s most important to us.

Sian Ferguson is a freelance health and cannabis writer based in Cape Town, South Africa. She’s passionate about empowering readers to take care of their mental and physical health through science-based, empathetically delivered information.

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