Understanding Religious OCD

In families with religious beliefs, a child expressing faith and strong moral principles is usually a welcome development. But sometimes a child’s faith may become an obsession, and instead of consolation the child experiences extreme anxiety that he is violating religious norms and desperation to correct his perceived mistakes. This is what happens when children develop obsessive-compulsive disorder and it manifests itself in their religion.

Not all people with OCD will develop religious obsessions or compulsions, but it is a theme that is fairly common. Other common themes include obsessing over cleanliness, symmetry and “bad thoughts” including sexual obsessions.

Sometimes it can look like a person’s faith is causing his symptoms, but religion is more like an unfortunate bystander along for the ride. If you think about a person with OCD who worries about germs and washes his hands compulsively, it’s clear that the germs aren’t causing his behavior; the OCD is responsible for it. Religious OCD works the same way.

“It could happen to any religion, but it’s not about religion, it’s about OCD,” explains Jerry Bubrick, PhD, a clinical psychologist at the Child Mind Institute. “We don’t treat people with religious OCD like they’re religious zealots, we treat the condition.”

Religious OCD is also sometimes called “scrupulosity.” We don’t use the word scruple often anymore, but it means a moral misgiving or a pang of conscience. The Latin word it comes from literally means a sharp stone or pebble, and Cicero used it figuratively to describe feeling uneasy or anxious, as a person would if he had a pebble in his shoe.

In the case of religious OCD, or scrupulosity, instead of a pebble in the shoe a person is troubled with religious worries, but she finds them just as persistent and disturbing.

For example, someone with scrupulosity might worry that she didn’t say a prayer correctly — maybe some of the words were out of order, or she didn’t say it with the proper reverence. She might fear some religious consequence from this, so she says the prayer again — and possibly a third and fourth time — as a correction. She might worry that she doesn’t do enough good deeds, or worry that she only does good deeds for selfish reasons. She might worry about having blasphemous thoughts and offending God.

Dr. Bubrick describes treating a 12-year-old boy named Matt who had religious OCD. Matt’s family was religious, but not very religious. Matt’s scrupulosity was debilitating.

“He worried about literally everything he did: ‘Did I do that because God wanted me to or did I do that for the devil?’” Dr. Bubrick says. “Opening doors, sitting down, standing up, doing his homework. Every single action he worried whether it was for the right reason or the wrong reason.”

Agonizing over everything he did was exhausting, so Matt started avoiding doing things because, he reasoned, it was safer. One of the things he stopped doing was eating, and he lost so much weight he actually needed to be hospitalized.

Matt also had compulsions, or things that he did to try to alleviate his anxiety. He had a particular prayer that he would say, he would carry a bible around with him during the day, and he slept with a bible under his pillow and one on each side of his head at night. He asked his grandparents repeatedly for reassurance when he was feeling worried.

Treatment for OCD always begins with helping young people and their families understand how their symptoms are caused by OCD. The obsessions and compulsions that people experience are powerful — in Matt’s case, powerful enough to put him in the hospital — but understanding how the disorder works starts to give people some of that power back.

People with OCD perform compulsions to fend off or neutralize the anxiety they are feeling, which is caused by things like unwanted thoughts, images or impulses. These are known as obsessions. But people with OCD do not always realize that a mental health disorder is behind these thoughts and behaviors. In the case of scrupulosity, they might mistake praying compulsively as an appropriate response to a blasphemous thought. They don’t realize that their OCD is behind the thought.

Helping people understand what’s coming from OCD and what’s coming from religion is essential. “If you want to pray because it brings you peace and you feel connected, that’s wonderful. But if you are praying because you fear if you don’t then you’ll be punished, then maybe that’s more OCD,” explains Dr. Bubrick.

The treatment for OCD is something called exposure with response prevention, or ERP. It works by exposing people to the things that cause them anxiety gradually and in a safe environment.

The child doing the exposure learns to tolerate the anxiety that he is feeling and, over time, discovers his anxiety has actually diminished. Then he is ready to take on more challenging exposures.

To make sure the exposures aren’t too difficult, at the beginning of treatment the child will work with his clinician to rank the things that cause him anxiety, from minor stress to major worry. Then they will tackle the symptoms one by one, together.

In the case of Matt, a lot of his exposures involved his anxiety about the devil. “We would do things like listen to music that had the word ‘devil’ in it because as soon as he would hear the word devil in a song he’d turn it off,” says Dr. Bubrick. They also listened to music with the word “hell” in it, ate devil dogs, and made Matt a jersey to wear with the number 666. These were big steps forward for a boy who had been effectively immobilized by his anxiety, but the steps were taken gradually and with great care. “We were breaking the association between God and fear,” explains Dr. Bubrick.

One other very important part of treatment is teaching other people in a child’s life how to respond to her OCD. A big part of the disorder is asking other people for reassurance. This can take different forms, including:

• Asking questions, like “Did I just commit a sin?” and needing a definitive answer
• Wanting people to participate in rituals, like compulsive praying
• Demanding that others avoid her anxiety triggers, like not saying certain words or doing certain activities in her presence

Getting reassurance makes the child feel better in the moment, so families provide it because they think they are helping. But reassurance-seeking is just another compulsion, and when people give reassurance they are participating in the compulsion and inadvertently feeding the OCD.

That’s because receiving reassurance once is never enough for a person with OCD. The requests will come again and again in an endless cycle that doesn’t address the root of a person’s anxiety, and actually makes the anxiety stronger. It also makes people with OCD feel dependent on those around them to feel (temporarily) better. Psychologists call this reassurance process “accommodation.”

As part of treatment Dr. Bubrick explains to family members how to recognize OCD symptoms, and how to avoid accommodation and instead encourage children to use the skills they are learning in therapy to deal with their anxious feelings in a more healthy and productive way.

In the case of scrupulosity, it often makes sense for religious leaders to be made aware of the OCD, too. That’s because they are often asked for reassurance and naturally believe that it is their role to provide guidance and answer questions.

Dr. Bubrick gives an example of treating a child who was worried about offending God so he would seek a lot of reassurance from his rabbi.

“I talked to his rabbi and explained to him the difference between OCD and scrupulosity versus being religious. The rabbi understood it very easily because he had been asked for reassurance thousands of times. So I taught him to do the same kind of support that I would teach the family.”

That includes denying kids the definitive answers to religious questions that they are often seeking. As Dr. Bubrick puts it, “You can’t answer every question. At some point you just have to have faith.”