Challenges and Pearls of Evaluation and Treatment of Adolescents and Emerging Adults With Scrupulosity Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) affects approximately 1% to 2% of youth.¹ Patients with OCD may present with varying degrees of insight into the excessiveness of their compulsive behaviors. This is certainly true among youth, of whom 20% to 45% are thought to have poor or absent insight.² Scrupulosity OCD-characterized by intrusive guilt and fear about moral or religious wrongdoing-is associated with worse symptom severity and insight.³ This form of OCD involves obsessive fear about offending a deity or acting immorally, leading to compulsions like excessive praying, reassurance-seeking, and avoidance of perceived immoral activities. Ritualistic practice and seeking penance are accepted practices in many religions, thus the line between acceptable religious observance and OCD is both difficult and important to distinguish. This may be especially true among adolescent populations who are in the process of developing and internalizing a moral identity. Because scrupulosity rituals may be seen positively within religious communities, diagnosis and treatment are sometimes delayed³. In this article, we present two de-identified cases of adolescence-onset scrupulosity OCD that feature some additional diagnostic challenges and highlight specific recommendations (ie, "pearls" of wisdom) for this youth population.