Organized Chaos - Volume 4
God Forbid
by Dr. Steven Phillipson, Ph.D.
Scrupulosity is the legal, ethical and moral preoccupation with doing the correct thing at all times.
Obsessive Compulsive Disorder is conceptualized as having three types or categories. The most traditional type is that of the observable ritualizer. These people perform ritual behaviors that are designed to undo or escape threats, such as, contamination or checking rituals to prevent some disaster. This type of OCD, the predominant concern is the protection of one's own well being and safety.
The second predominant form of OCD, is the purely obsessional type. These are the "non-observable ritualizers." I call this type of OCD: "Pure-O."
The third category of OCD, is the one that is the most difficult to treat. I refer to this type of OCD as the Responsibility OC, which encompasses two subtypes. One subtype is scrupulosity. The other, hyper responsibility, is excessive concern with the well being of others.
The term, "scrupulosity" was first heard in the 1600s. It was used by monastic priests. It described the situation where certain priests never felt they engaged in their daily religious rigors to a satisfactory level. These people were preoccupied with the concern and fear that they were not satisfying God's need for them to display love in an adequate way. Their typical rituals included the need to pray in an exact way or with an exact level of emotional intensity.
Four hundred years later, scrupulosity is a well-documented form of OCD. It is evident in persons who have an overzealous concern that their behavior or thoughts are in some way displeasing to or disrespectful toward God.
This preoccupation involves not only the traditional experience of anxiety, but the presence of guilt as an additive component. It seems as if there is a grave vulnerability with this condition to feeling that ones character is flawed and damaged in God's eyes.
The scrupulosity type of OCD takes on many different manifestations. There are people who experience an intrusive thought that involves some disrespect to God or to religious items or ideals. The spike involves the threat that an irreverent idea or an incomplete prayer could displease God and, therefore, endanger the perpetrator's chances for salvation or happiness in the afterlife.
Examples Of Scrupulosity
An orthodox Jewish man wakes up and performs his morning prayers. He does this in a slow and deliberate way. It is his goal to make sure every syllable of every word expresses his sincere and profound experience of love and respect for God. Each morning, his mind finds moments or words which do not completely demonstrate an adequate amount of love and reverence for God. When this happens, his mind dictates that he must start the prayer over again from the beginning and keep doing this until he recites it perfectly.
When weeks and months go by, the task of achieving the perfect prayer becomes increasingly difficult. This attempt at perfection disrupts the man's life. It interfers with his ability to get to work on time or to focus on other daily activities. This person asks his rabbi to allow his wife to perform the morning prayer for him or that he be given special permission to skip this prayer in its entirety. This rabbi gives him permission to have his wife perform his morning prayer. However, within a month, his mind creates other ideas that threaten his sense of well being and his relationship to God.
An altar boy, in church sees a statute of the Virgin Mary and experiences intrusive thoughts about her genitalia. When these intrusive thoughts appear, he experiences tremendous guilt, disgust and shame. He feels compelled to pray to God for forgiveness. He then goes to confession to have this apparent sin removed from his soul. After a few months, the priests from his parish suggest that the altar boy inform his parents that he needs to see a psychologist.
Scrupulosity does not focus on religion only. Some people have secular scrupulosity, that manifests itself in their concern for strictly observing legal standards and societal mores. I treated a patient, an attorney, who felt the need to check his briefcase everyday to ensure that he was not stealing a pencil or a blank piece of paper from his law firm. This person went to extraordinary lengths to make sure that all the money in his pocket or wallet was his own. In this form of scrupulosity, there is a sense of guilt. It is not tied to specific religious beliefs or observances.
A feature of this form of OCD is that it is often accompanied by a specific type of personality structure. A personality that tends to view themselves and the world around them in a very rigid and perfectionistic way. It seems that with this type of OCD, there is an anxious need to achieve a sense of strict adherence to one's religious and/or moral beliefs. There is also a pervasive pattern of perfectionism and of being judgmental in other aspects of living. When a person has this form of OCD, he may also have Obsessive Compulsive Personality Disorder (OCPD), which is a separate condition. In order to effectively treat a person in this situation, a mental health professionals has to determine whether one or both of these disorders are present.
OCPD often involves a secondary threat. I call this element, "character assassination." A woman I worked with had thoughts that her love for her child, or her love for God, was not sufficient. Therefore, she was morally corrupt. She obsessively sought reassurance from her spiritual adviser and from family members. She needs to know that her love and attention towards her child, along with her religious practices, fell within what would be considered an adequate demonstration of devotion.
Another example is a patient I treat who is involved in a Weight Watchers eating program. She feels the need to report every dietary choice. On occasion, questions arise as to whether she accurately reported the amount of butter she have placed on a bagel. She constantly questions whether she's been 100% honest in reporting what she ate. She is concerned about the accuracy of her report if she does not include the fact that a small portion of food fell off her plate and she did not eat it. She can't tell a story because she has to include every detail.
The additional element of "guilt" or "character threat" can be as compelling and distressing as the more predominant anxiety feature of OCD. A patient, who started Prozac at the outset of her treatment with me, reported that the anxiety related to her scrupulosity was completely gone within a month. Her attachment to performing rituals was not at all affected because of an overriding sense of guilt and her belief that without doing them, she was a person of "bad character."
Scrupulosity can cause hyper zealous search for absolute honesty in the spoken word and absolute legality in one's life choices. It can completely disrupt one's ability to live a normal life. Persons who suffer from scrupulosity in regards to being honest will often engage in time-consuming rituals in which they review in painstaking and minute detail ordinary everyday interactions. This review guarantees that they did not, provide misleading or false information. They fear that they will feel tremendous guilt if they have "sinned" by conveying information that may has damaging effects to those who listened to them.
There's a heightened scrutiny following almost every ordinary conversation. The scrupulous person examines the conversation to determine whether or not they have, uttered an obscenity or something offensive to the listener. This intense scrutiny occurs when the scrupulous person is writing. They check all their correspondence repeatedly to ensure that there's no misleading information or no vulgarities included in the correspondence.
Scrupulous people, who are hyper vigilant about legal constraints, engage in a rigidly controlled lifestyle. They feel compelled to avoid any potential legal conflict. A common manifestation of this form of OCD is an attempt on the part of the sufferer to ensure that his/her written work does not contain any plagiarism or ideas that are not uniquely their own. This determination to "not cheat" sometimes compels the hyper vigilant person to overburden his writing with footnotes. This includes crediting "Spell-Check" with the correct spelling of a word. There is a combination of anxiety due to not knowing whether one has crossed the line, morally or ethically The guilt of having violated the law, harmed innocent "bystanders" or defied the will of God is a concern. In developing a treatment plan, a therapist has to remember that a person with this type of OCD does not find it easy to differentiate between their fears and objective moral and ethical standards.
This form of OCD involves what is called "overvalued ideation." The patients suffering from OCD are aware that the threats that they encounter are irrational. This dichotomy of thought is they feel compelled to perform a ritual and, on the other hand, are aware that the originating threat is irrational. This produces a great deal of turmoil. With scrupulosity, there is increased risk that the patient is not aware that the threat is of an irrational nature. It's as if the disorder has prevented the sufferer from thinking rationally about these "moral and/or ethical" issues. The tendency to overvalue the irrational threats and consider them logical and justified diminishs the prognosis of treatment success.
Treatment Considerations
Patients with scrupulosity OCD perceive the risk in treatment as being greater than the risk of an individual whose OCD is concerned with contamination. They feel that they risk eternal damnation, not just disease or illness or even death. They feel that the risk involves not only their physical well being, but also the risk of disapproval from God. This perceived heightened risk produces a greater level of resistance from the patient to perform the exposure exercises, that are necessary for treatment. These exposure exercises must be approached in an aggressive, determined manner in order for clinical outcomes to be positive.
Medication is a very powerful frontline treatment for Obsessive Compulsive Disorder It sometimes has limited benefit for persons with scrupulosity when the existence of this overvalued ideation is present. The treatment course for scrupulosity does not deviate significantly from other types of OCD. Generally, a hierarchy is constructed, in which persons gradually are exposed to accelerating levels of risk. This involves increasing levels of risk that their character might be negatively judged. Exposure exercises at the lower level entail things, like a person sampling a grape at a deli. Then walking away as if they're disapproving, but in their heart knowing they're stealing a grape. Another example of an exposure exercise might entail a patient dropping very small amounts of litter on a public street. An example of a middle range exposure exercise involves a patient repeating to himself through the day that the Virgin Mary might not have been a virgin.
This form of OCD involves the double-barrel threat of anxiety plus character indictment, it is often recommended that a patient's treatment include the more philosophical cognitive principles that contradict the belief or notion that people have definitive and specific characters. The principles of cognitive therapy hold that humans are fraught with imperfection and diversity. It is not considered adaptive for humans to attempt to assess their stature overall, ego, character or place in God's eye. Cognitive principles encourage patients to perceive themselves as generic humans, without an additive sense of the goodness of character. Patients are encouraged to see that their behaviors can vary. That one should not judge himself too harshly based on isolated actions.
I can assure you that this therapeutic goal remains one of the most challenging within psychology. Our society, school system, and religious institutions continue to be fraught with ego-based philosophies that encourage people to become good or better persons. These ideas create a greater susceptibility for one's ego to be harmed or diminished.
It is not unusual that professionals within the religious community, like priests, rabbis and ministers, to be called in the initial phases of therapy to sanction the seemingly irreverent nature of this therapy. It is helpful if these religious professionals have some knowledge of OCD. They can understand that the treatment course is not designed to have any impact on religious beliefs and devotions. They should be aware that treatment is solely targeting a disruptive anxiety disorder, that produces "seemingly" devout behavior that is really unrelated to genuine faith or belief. It is not uncommon that persons are referred for therapy by significant others, or those within the clergy. Most people with scrupulosity do not perceive their excessive behavior as being dysfunctional.
The factor that distinguishes someone who is simply conscientious or concerned from one with responsibility OCD or scrupulosity is the amount of anxiety and/or guilt that they experience in not performing the task, or good deed. If the occasion were to arise, where we were to observe some potential hazard in the street, we have the freedom to ask ourselves: "If I were not to perform this good deed, what emotions would I experience?" If the answer is a significant amount of anxiety or guilt, or a strong feeling that you are less of a person for failing to act as your conscience dictates, this is a strong indicator that you suffer from responsibility OCD, and it might be in your best interest to seek professional help.
Steven J. Phillipson, Ph.D. is a Licensed Clinical Psychologist at the Center for Cognitive-Behavioral Psychotherapy located at 137 East 36th Street, Suite #4, New York, NY 10016, phone: 212:686-6886.
