What is it and how does it develop?
It’s an overdeveloped sense of right or wrong, always questioning what is morally correct. Oft times, a hyper-sensitivity to social etiquette.
Looking further, the etymology of scruple, goes like this: "moral misgiving, pang of conscience," and used figuratively by Cicero for a cause of uneasiness or anxiety, probably from the notion of having a pebble in one's shoe.
And isn’t that appropriate – people who suffer from scrupulosity are always gnawed at; like almost all OCD, but these people are gnawed at the notion that they did something wrong or are worried that they may be bad or have badness inside them ready to come out. These are people who were probably overly accommodating as children, perhaps because there was a mis-attunement with their parents, or in terms of religiosity, with their church or temple, what have you.
And so how do we treat this? Well, a history is in order, first, to understand the course of symptoms – that is, have they morphed? When did they start? Etcetera… Then, after conducting a YBOCs, we begin to develop a trigger chart. Three columns are always best: One for the trigger, both internal and external, the obsession (what worries the person), then the compulsion (does one seek constant affirmation; are they apt to tell, ask, confess? Does one avoid? And so patient and I learn to slowly approach the triggers without giving into the compulsions. This is not an exercise in sadism; that is, the key word is ‘slowly.’ On the hierarchy of triggers, we start with 60’s (out of 100) and work our way up. Often pausing helps. Diffusing the sense of urgency. For example, if someone must seek affirmation from a loved one, can they delay it an hour? Can their phone call be 5 minutes and not 10? Can they tell their partner “I’m having an OCD,” but not elaborate? This is the behavioral side to treatment. And this template can apply to most any OCD symptom.
The second part is much more complex and goes deeper: It’s the psychodynamic part and is very important. We try to understand how these value systems were formed and enforced. And in the case of scrupulosity, we try to shatter them. Okay, that is grand. We try to tame them down. People learn to be ‘bad,’ which for the average person is probably still all too good. But patients with scrupulosity learn to care less about right and wrong; and for the most part, the patient with a scrupulous character will be good enough, certainly in alignment with what is socially proper, just not tortured by guilt and did I say that wrong or do this right. It’s a process toward saying ‘the hell with it, I’ll live my life.’ And in some cases, saying ‘hell’ might be the launching off point.