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Obsessive Compulsive Disorder and Scrupulosity

Fri, 17 Apr 2026 18:49:35 GMT

One of my biggest surprises and challenges since becoming a private practice psychiatrist is scrupulosity and OCD. There is an overlap of concepts, symptoms and treatments that would benefit from explanation. Nothing said here is meant to explicitly diagnose or treat OCD / scrupulosity. Please consult with a spiritual advisor and/or mental health provider.

Prediction Error

Think of a hunter who is looking for a deer in the woods. He clears his mind of all things but what he sees and hears. And with these two senses he looks for change. His mind projects a wooded environment without a deer and looks / listens for indications of a deer. Our minds predict our environments constantly. When you make a drive that you’ve driven many times before, you can be lost in thought until something novel occurs. Your brain does not passively take in sensory information. No, it is actively predicting where things are, how you should feel, what comes next, and what you should be doing. Our brains predict our experience and adjust along the way.

In OCD, prediction error does not shut off properly. For example, if I expect the garage door to be closed at night but happen to see that it is open, I close the garage door and the warning system ends. In OCD, the prediction error is not extinguished. The garage door is shut the first time but then the concern for it being open lingers. This anxiety feels significant and is relieved from compulsive checking.

In a sense, the alarm is only quieted, not turned off.

This sequence is so distressing that people with OCD begin to predict the prediction error. Now the alarm is not only hard to shut off but it activates too easily. Think of a fire alarm that activates when someone is cooking and only quiets down after a particular ritual. The brain learns that ritual = relief.

And then the thought loop thickens over time. Sometimes my patients and I call this, “solving the puzzle”. The problem is, the puzzle cannot be solved.

Exposure Response Prevention seeks to uncouple the “intrusive thought” from the circle. That gives space for the thought to pass without the feared outcome occurring. Now the intrusive thought is uncoupled from the ritual, there is an alternative pathway to relief.

Moral Failing

For persons of faith, moral failings can be totally catastrophic. Beyond all earthly consequences, the loss of grace for one's soul is severely distressing.

Sexual Impropriety

Intrusive thoughts surrounding sex can overlap with moral failing. A person questions the origin of the thought and wonders if they may act on them. What would others think if they knew of the thought (social rejection)?

Symmetry

The brain predicts that things should feel “right” – even, ordered, balanced – and when they don’t, a sense of wrongness persists that can’t be reasoned away. While there might not be the classic “fear” associated with other OCD types, there is a compulsion to order that brings temporary relief.

Checking / Contamination / Physical Harm

Checking the door is locked or oven off

Washing hands to avoid infection

Ensuring you haven’t hit someone with your car

The link between fear and association with survival is evident with these subtypes. In practice, I have seen these behaviors as able to be quantified (how much time spent on compulsion) as well as being responsive to medication. The straight forward nature of the fear and compulsion lend themselves to treatment whereas other OCD types can be convoluted in relation to a person's ego or sense of self.

Social Rejection

Social rejection used to have profound implications for a person. When our social circles were limited and local, discord within a group might have meant removal. Removal might have meant death. Our situation now is much different. Our social circle is not local, limited, and subsistence is not dependent on social standing. But this sensitivity to social position persists in many people. For a person with OCD, social rejection often intensifies the guilt and shame surrounding their symptoms.

Somatic

Somatic OCD involves a hyperawareness of bodily functions – breathing, swallowing, blinking, heartbeat. What would normally be automatic becomes conscious. The conscious behavior then becomes part of the obsession and compulsion.

The Scrupulous Patient

Scrupulosity is a subtype of OCD in which intrusive thoughts revolve around moral or religious failure. The obsessions center on sin, spiritual worthiness, or violating one’s moral code. The compulsions typically involve prayer, confession, or reassurance seeking.

A few things that make scrupulosity difficult:

Distinguishing what is sin, venial sin, or mortal sin is difficult to discern
What is healthy repentance versus compulsions
Many subtypes of OCD overlap in Scrupulosity

Often the most difficult with Scrupulosity is the question of primary mental health concern vs spiritual attack. Separating symptoms cleanly between the two is almost impossible and they often co-exist. A spiritual matter may have a mental health component and vice versa. So what we are left with is the understanding that engaging in compulsive behavior strengthens the loop of compulsion for temporary relief. Exposure Response Prevention and medication give the mind space to let the thought pass naturally. Over time, the person learns that distressing thoughts can resolve on their own – and that the feared outcome, more often than not, does not occur.

But this subject is nuanced and complex. Every patient feels they have this specific loop and the time where they experience relief, it feels solved. But then it recurs. Often a three pronged approach is required for treatment of Scrupulosity

1. Spiritual Advisor to discern for when confessing is appropriate vs compulsion and need for specific prayer

2. Therapist for Exposure Response Prevention work

3. Psychiatrist for medication management to reduce symptoms which can allow for therapy and spiritual advisement.

Conclusion

I hope you found this helpful. OCD and Scrupulosity affect some wonderful people, and the cycle of symptoms can pervasively impact every aspect of daily life. My hope is that this post provided a basic understanding of OCD, scrupulosity, and the importance of seeking the right treatment. Thank you for taking the time to read.

Can Christians Take Psychiatric Medication?

Sat, 07 Mar 2026 19:32:14 GMT

Reflections from a practicing psychiatrist and Christian

There is a reasonable skepticism amongst Christians regarding psychiatric medication.

1. Will taking medication change my soul?

2. Is medicine the easy way out, just go numb?

3. Shouldn’t I bear the cross that is given to me?

These are heavy and enduring questions that have prevented Christians from seeking medication treatment since it became an option. Combine these concerns with the developing mistrust of our medical industrial complex and the barrier to sometimes necessary care can be hard to overcome.

Let's take a step back from these valid concerns and think about how the body and mind affect one another. Did you know that inflammation can cause depression and that people with high inflammation often have depression? Which happens first? Oftentimes it is both! Depression can lead to low energy, which contributes to inactivity and poor diet; these, in turn, increase inflammation, further worsening depression. This is a “positive” feedback loop.

Positive feedback loops occur when output amplifies its own input. A classic example is a microphone squeaking when you put it up to a speaker. Positive feedback loops can get you to a place you never expected (the loud screech!) and require meaningful action to stop (get that microphone away from the speaker!). Mental, spiritual and physical health are no different.

I’ve encountered patients, oftentimes with a history of trauma, that have so much anxiety that they cannot participate meaningfully in therapy! I’ve had patients who were too depressed to make the lifestyle changes needed to improve their depression! Here we see the “positive” feedback loop keeping a person in suffering. While there are multiple ways of reversing this course, psychiatric medication can be meaningfully helpful.

Many things affect mental health in a secondary way. Let's say you eat because you are hungry. The quality of the food you eat will affect your mood and energy level. Let's say you scroll on a social media feed, the duration and type of content will affect your mood. The primary reason you look at the feed may be boredom but there are secondary effects to mental health.

Antidepressants were discovered as a secondary effect. Isoniazid is an antibiotic that was found to significantly boost mood in patients receiving it for the treatment of tuberculosis. Imagine a hospital ward with malaised sickly persons when suddenly some patients became bright and cheery! Isoniazid has “MAOI” properties and the discovery of this class of medication preceded our current antidepressants.

When many behaviors affect our mood, affect our soul, why is it that we seem to ask those questions more frequently when it comes to psychiatric medications? Is it because the “primary” effect of psychiatric medication is to change us? Well so does everything else. And maybe we need to consider our mental health and soul more often with other decisions.

So then psychiatric medication can be seen as a tool. A tool that when used appropriately can have profound effects on a person's life. But they must be used judiciously and not in place of proper discernment.

Discerning the use of psychiatric medications starts with assessing for symptom cause, not jumping to symptom management. Looking at multiple domains including physical, spiritual, and social wellbeing. Ordering what is disordered. When a person is using marijuana or drinking or scrolling all day, the “mental health symptoms” are there to tell us that something needs to change! The last thing we should do is treat the downstream effects of maladaptive behavior without trying to fix it. Or if someone has a medical problem such as anemia or thyroid disorder, treating the energy level symptom would just mask the underlying pathology.

There are times though when everything seems mostly ordered and yet functionally a person is struggling. Genetics, trauma, or substance use – sometimes these push a person so far into the positive feedback loop of mental illness that they can’t engage in talk therapy and lifestyle changes. The velocity is too strong to be reversed. In those instances, medication can be life saving.

And so back to the initial concerns of the discerning Christian. Will taking medication change my soul? Any action has a multitude of consequences, intended or not. Psychiatric medication has an intended effect of improving mental health but that doesn’t make it an inherently good or bad tool. Is medicine the easy way out, just go numb? By the time someone is considering taking medication, they often have been trying alternatives. Medication can give space for other interventions and improve mental health, but for most, they aren’t an easy solution. Shouldn’t I bear the cross that is given to me? Jesus was helped to carry the cross by Simon of Cyrene.

If you are a patient considering pharmacologic mental health treatment, I would encourage you to find a provider that is as cautious as you are. They exist. More and more our patients and healthcare providers are moving toward a holistic approach. Why? Because drive-thru healthcare improves symptoms at best. And what people are looking for is wise, targeted, lasting change. That involves buy-in from the prescriber as well as the patient. Sometimes an honest look at the “domains of wellness” can be difficult for a patient. But if you are honest with yourself and provider and willing to put in the work, medication can be a helpful part of the journey to stable mental health.

Dr. Justin Hendricks is a psychiatrist and founder of Mirror Health, a telehealth practice focused on holistic and faith-informed mental health care.