“Thank you for telling me about this, I think you’re going to be fine,” his bishop said.
Despite all the fear and all the worry David Johnson felt, an immense sense of relief washed over him as he sat in his bishop’s office.
“I’m clean again, I can feel peace again, I can feel good again!” David thought. “And yet …”
“What if he didn't understand me correctly?”
“Or what if I left out this detail?”
“Was I trying to sugarcoat it?”
“Maybe I was even lying about how severe this was.”
“I'm going to have to go back in and redo all this.”
It wasn’t until his early teenage years that David Johnson and his family understood he was suffering from a unique subset of obsessive-compulsive disorder: scrupulosity.
This is a typical example of the thought pattern for those with scrupulosity. One that left Johnson living in constant worry about his standing in the eyes of God.
“I remember feeling like the worst person in the world and feeling this overwhelming weight of guilt and it kind of consuming me all the time,” Johnson said. “I remember feeling so sad for a long time, wanting so badly to feel worthy and not really understanding why I couldn’t, pleading with Heavenly Father over and over again.”
Johnson’s experience is not unique. BYU assistant clinical professor Brodrick Brown, Ph.D., said that students often come into his office at BYU’s Counseling and Psychological Services exhibiting signs of scrupulosity. After four years working at CAPS, Brown specializes in treating students with OCD and anxiety disorders.
While scrupulosity itself is not an officially recognized disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR), Brown described it as a sub-type of OCD that specifically deals with having intense and obsessive thoughts surrounding issues of morality, religion or ethics, as well as compulsive behaviors that give some form of relief from obsessive thoughts.
People with scrupulosity tend to be very concerned about the idea of being a good person and what that means. One example Brown gave of an issue a person with scrupulosity might fixate on is choosing what outfit to wear.
“Even something as mundane as that can, for someone with scrupulosity, feel like it has a moral or a higher weight to it,” Brown said.
When even the smallest choices seem to hold someone’s eternal salvation at stake, they may turn to extreme measures to deal with the stress.
“The people do that compulsion, they get some relief from it, from the anxiety,” Brown said, “and then that cycle continues.”
Textbook OCD.
OCD is not, as is commonly portrayed in media, a simple desire to keep things clean and orderly. The DSM-5-TR, by the American Psychiatric Association, defines OCD as the “presence of obsessions, compulsions, or both.”
An obsession is defined as recurring and persistent intrusive and unwanted thoughts, urges or images that in most individuals, cause marked anxiety or distress. The individual attempts to ignore or suppress these thoughts, urges or images, or to neutralize them by some other thought or action.
A compulsion is a repetitive behavior that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. These behaviors or acts are intended to prevent or reduce anxiety in the individual despite not being connected in a realistic way with what they are intended to neutralize or prevent, or are clearly excessive.
Brown said individuals with scrupulosity may start with an anxiety disorder or general OCD that “attaches itself” to their religion due to the structured nature of their belief system.
“I wouldn't necessarily say that religion causes scrupulosity,” Brown said. “But scrupulosity can feed off religion and change religious beliefs from being something that can provide meaning and hope and even structure in life and transform that into something that is harsh and intense and terrifying.”
Brown’s claim may be further corroborated by a 2015 study published by BYU associate professor G. E. Kawika Allen, Ph.D. While focusing more on the psychological difficulties that may be caused by some forms of religious living, the study found that “the factor that is correlated with distress is not religious commitment, but rather strong legalistic beliefs with a distorted focus on never being good enough for the family.”
Legalism, according to the same study, is the belief that one must work to experience God’s love and acceptance.
Allen is the leading researcher on scrupulosity in Latter-day Saint populations. He first began publishing scientific papers on scrupulosity in 2014.
Allen said the research surrounding scrupulosity itself is somewhat limited due to the complexity of the matter, as well as the relatively recent interest in scrupulosity as a research subject.
“We're still at the very, very early beginnings of what this looks like for Latter-day Saints,” Allen said. “How do we describe it or define it among LDS people? Because that's a very specific group of people, and scrupulosity across different religions might look different, and the manifestation might look different.”
In his research, Allen said he uses the Penn Inventory of Scrupulosity, or PIOS. The PIOS defines scrupulosity in a slightly different way than Brown’s OCD-based description. Allen’s use of PIOS defines scrupulosity as “a fear of punishment from God and a fear of offending God through sinful activity.”
“Those two fears pretty much make up someone who struggles with scrupulosity,” Allen said.
In their first seminal study in 2014, Allen and his colleague Kenneth T. Wang Ph.D., found that scrupulosity, using the PIOS definition, and maladaptive perfectionism decreased life satisfaction as well as increased anxiety and depression.
While some chastened Latter-day Saints may turn to God when they feel they fall short in important aspects of the gospel, those with scrupulosity may do the opposite.
According to a 2023 study using the PIOS definition, “scrupulosity is positively associated with anxiety about and avoidance from God. These attitudes or behaviors may be detrimental to their relationship with God, intrinsic spirituality, and self-esteem.”
A 2021 study from Allen suggested a positive correlation between PIOS scrupulosity and maladaptive perfectionism.
But while scrupulosity may seem similar to toxic perfectionism, Allen explained the difference.
“Scrupulosity has similar undertones and underlying features and characteristics of perfectionism, but it's all manifested through religious thoughts, feelings and behaviors completely,” Allen said.
Discussion around toxic perfectionism in Latter-day Saint culture gained popularity when Elder Jeffrey R. Holland gave a talk titled “Be Ye Therefore Perfect — Eventually” in the October 2017 General Conference.
“It's interesting how he came about that topic or idea because I don't see it a lot in the scientific literature I read,” Allen said. “I would use the term maladaptive perfectionism.”
In an article in BYU Studies titled Understanding Perfectionism, Allen defined maladaptive perfectionism as when someone sets unrealistically high standards and is never satisfied with the discrepancy between their standards and their actual performance.
In contrast, adaptive perfectionism is when someone has similar standards and expectations as maladaptive perfectionism but doesn’t get discouraged, distraught, or depressed if they’re not able to meet those expectations. While still likely to be concerned about making mistakes, they are more able to adapt to changes in their environment and relationship compared to maladaptive perfectionists and nonperfectionists.
In their 2014 paper, Allen and Wang examined a Latter-day Saint population of 267 people. Of those in the study, 47% were found to be adaptive perfectionists, 30% were maladaptive perfectionists and 22% were classified as nonperfectionists.
“That's a good thing,” Allen said. “It was a pretty good number in terms of like, we're not too distressed over these things. We're not struggling too much with this kind of issue.”
While maladaptive perfectionism may be less of an issue in Latter-day Saint populations than commonly believed, Allen said scrupulosity is still a concern.
“I don't know if it's increasing, but I do know that it's within our families, at the ground level, in our wards and stakes,” Allen said. “All you need is someone who's a little bit more inclined to be anxious on average than another person, and then their scrupulosity is manifested through that anxiety disorder.”
Allen suggested in Understanding Perfectionism that the way certain topics are discussed in church could help lessen struggles for some members.
“Scrupulosity and shame could be avoided if therapists, parents and church leaders teach a more accurate definition of grace — avoiding the idea that God’s love must be earned with behavior,” Allen said.
For individuals currently suffering from scrupulosity, Allen shared his advice.
“Don't just believe in Him and believe in Jesus, actually believe Him when He says that you can be healed. Believe that His Atonement works, believe that His grace is sufficient for you,” Allen said. “That’s one. Number two, continue what you're doing, reading scriptures, go to the temple. Do all that and then also seek help, professional help, professional services.”
Scrupulosity is typically a long-term condition, Brown said, but patients are taught ways to handle their distress without giving in to their compulsions.
When providing counseling for individuals with scrupulosity or anxiety disorders, Brown said the “gold standard” is exposure and response prevention. Through this method of treatment, patients are intentionally exposed to their thoughts, images or situations that trigger their obsessions while helping them resist the urge to perform their compulsions in response.
For patients who often engage in “automatic prayers” as a response to their triggers, this treatment can be uncomfortable.
“Instead of feeling like, ‘Oh, I have to pray right now or I'm going to go to hell,’” Brown said, “It's, ‘I am choosing to pray right now because I want to communicate with God.’ And so, then that allows them to actually reestablish the meaning.”
In addition to counseling and other professional services, Brown shared what he believes might ease the burdens of those with scrupulosity.
“I think being more gentle with people in their struggles, especially when it comes to religious things, making sure that we're being loving and understanding and trying to understand their perspective,” Brown said. “I think being less all-or-nothing about things in general is helpful. I think it is for everyone, but especially for people with OCD because it's just such a torture.”
Allen and Brown’s insights into the academic and clinical aspects of scrupulosity help make sense of the experiences people with scrupulosity live through, people like David Johnson.
David Johnson has come a long way from his early teenage years, struggling with his scrupulosity in his bishop’s office.
“I just feel less afraid now. I'm at the point now where there's no way that I could be considered to have scrupulosity, like, I’ve probably swung too far the other way,” Johnson joked.
Johnson is now finishing his third year of grad school at the University of Alabama at Birmingham, working on his Ph.D. to be able to become a therapist specializing in scrupulosity.
“I'm at the point where I feel like I’m grateful for this in my life,” Johnson said. “It's led me to so many people that I feel like I've learned from and been able to help. It's literally the career I've chosen.”
For those still struggling with the obsession and compulsions of scrupulosity, Johnson offered some words of encouragement.
“Forget about being perfect and just try to be healthy. Just heal and then you can actually make progress towards who you want to be as a person in a healthy way,” Johnson said. “Getting healthy and healing is the priority. God knows you have scrupulosity. He is endlessly patient with us as we navigate that journey.”