by Steven J. Phillipson, Ph.D.
The Center for Cognitive-Behavioral Psychotherapy
Scrupulosity: The over-concern for doing the correct thing both in God’s eyes, and that of the law.
Obsessive Compulsive Disorder is conceptualized as having three types or categories. The most traditional type is that of the observable ritualizer. In these people, rituals generally involve behaviors which are designed to undo or escape threats; such as contamination or checking rituals to prevent some disaster. In this type, the predominant concern is the protection of ones own well being and safety. The second most predominant form of OCD, which is just recently beginning to receive a modicum of attention, is the purely obsessional form of OCD, or technically the non-observable ritualizers, which I refer to as the Pure-O.
The 3rd category of OCD, which has received remarkably very little attention, is actually the one in which treatment is most difficult and convoluted. I refer to this type of OCD as the Responsibility OC, which encompasses two subtypes. One subtype is scrupulosity, while the other subtype is over-concern with the well being of others. Both subtypes essentially entail an exaggerated need to defend ones character from agreagious self deprication or disrespect from others.
Scrupulosity is a term given birth to in the 1600s amongst the religious monastic priests of the time. It was observed that certain priests never felt as if 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 and or reverance in an adequate way. Typical rituals that were observed in that time involved the need to pray in an exact way, or to pray achieving an exact level of emotional intensity. Four hundred years later scrupulosity is a well-documented form of OCD. It is typically evident in persons who have an overzealous concern that their behavior or thoughts may in some way be displeasing, or disrespecting to God. Repetitive and excessive prayer continue to plague those persons with this type of OCD. Scrupulosity also can involve the need to adhear to a strict code of values or ridigidly follow the ethics of a law abiding citizen.
This preoccupation involves not only the traditional experience of anxiety, which is a feature predominant in all forms of OCD, but the presence of guilt as an additive component further exasserbates the pain and complicates treatment success. OCD obviously is associated with a two part process. There is the upsetting or threatening thought and this thought is usually immediately followed by tremendous anxiety. Although this is the pervasive pairing of OCD there are occasions where the originating thought can produce guilt, anger and or depression.
The Scrupulosity type of OCD takes on many different manifestations. There are those people who will 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 creates the risk of potential displeasure of God, and therefore that ones spiritual afterlife will be affected negatively.
Some examples of scrupulosity are as follows:
An orthodox Jewish man wakes up and performs his morning prayers. He performs his prayers in a very slow and deliberate way, his goal being to make sure every syllable of every word expresses his most sincere and profound experience of love for God, and respect for God. Each morning, as his effort to achieve this perfect sincerity is played out, his mind finds moments or words which may not completely demonstrate an adequate amount of love and reverence for God. At this moment, his mind dictates that he must start the prayer over again from the beginning, and go through it to the point of absolute perfection.
As weeks and months go by, the task of achieving the perfect prayer become increasingly difficult, and his life is disrupted in his ability to go to work on time, or to focus on other life matters. This person requests from a rabbi that his wife be allowed to perform the morning prayer for him, and that he be given special permission to skip this prayer in its entirety. This person is given permission by the Rabbi 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 relationship to God.
Another example involves an altar boy, who in church sees the Virgin Mary, and experiences intrusive thoughts about the Virgin Mary's genitalia. When these intrusive thoughts appear to the altar boy, he feels tremendous guilt, disgust and shame. He feels compelled to pray to God for forgiveness. He then attends confession in order 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 sees a psychologist.
Scrupulosity need not focus on ones involvement in a religious sense. Some people have scrupulosity in terms of their concern for remaining within strict rigors of legal standards and societal mores.
A patient, who is an attorney, 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 would go to extraordinary lengths to make sure that all moneys in his pocket or wallet were accounted for as being his own, and not accidentally taken or placed there by someone else. In this form of scrupulosity, there is still an indicting aspect where the person might consider himself legally corrupt, with or without the presence of there being a religious threat, or indictment to his character.
A complicating feature of this form of OCD is that it tends to be accompanied with a specific type of personality structure, in which patients tend to view themselves and the world around them, in a very rigid and perfectionistic way. It seems that with this subset of OCD, not only is there an anxious need to achieve a sense of perfect harmony in ones religious and/or moral beliefs, but there is also pervasive pattern of perfectionism and of being judgmental in other aspects of living. There is a chance that when a person has this form of OCD; they also have an accompanying personality disorder, referred to as Obsessive Compulsive Personality Disorder (OCPD). It is essential for mental health professionals to create differential diagnoses in order to ensure that the standard protocol for treating this form of OCD possibly takes into account the less rigorously studied treatment, which attends to the patients personality structure.
The aspect of this personality condition often and almost entirely involves a secondary threat, of what I call Character Assassination. A woman I worked with had thoughts that her love for her child, or her love for God, was not sufficient, and therefore she was morally corrupt.
Her rituals would involve constant reassurance from persons within the clergy, and from family members, to ensure that her love and attention towards her child, along with her religious practices fell well within what would be considered an adequate demonstration of devotion.
A woman is involved in a Weight Watchers eating program. She feels the need to report her every dietary choice. On occasion, questions will arise as to whether she has accurately reported the amount of butter she might have placed on a bagel. Questions also ensue to whether she’s been 100% disclosing and honest in giving an accurate account if small portions of her food might fall off the plate. She is incapacitated in telling stories by the need to make sure that she’s included every detail, lest she be accused of being withholding information while not being completely honest and disclosing.
The additional element of “guilt” or “character threat” can be as compelling and distressing as the more predominant anxiety feature of OCD.
A patient came to me, and started Prozac at the onset of treatment. Within one month, the anxiety related to her scrupulosity was completely gone, yet her attachment to performing rituals was not at all affected because of her guilt, and her need to rid herself of the potential for her character indictment.
Within scrupulosity, issues of absolute honesty in the spoken word, and absolute legality in ones life choices, can become disruptive in the hyper-zealousness with which people feel compelled to live within. Persons who suffer from scrupulosity in regards to being honest will often engage in time-consuming rituals, in which they feel the need to review exchanges that were taken place on an interpersonal level. This review is intended to guarantee that there were no instances of providing misleading or false information. In this regard, persons once again feel the threat of guilt if they conveyed information that may have damaging effects to those who listened to them. There’s also a heightened scrutiny following any conversation where the person will strictly evaluate whether or not they have, unbeknownst to them, uttered an obscenity or some offense to the listener. This also tends to occur in written language to these people, such that they will check any correspondence repeatedly to ensure that when it leaves their control, there’s no misleading information, or no vulgarities included in the correspondence.
Persons who have a hyper vigilance about legal constraints will engage in a rigidly controlled lifestyle in which they feel compelled to avoid any potential legal conflict. A common manifestation within this form of OCD involves persons who are hyper-vigilant to ensure that their written information not contain any plagiarism, or contain ideas that are not uniquely their own. This determination to remain completely within the ethical guidelines, seen as “not cheating”, can manifest themselves in people placing footnotes on any written correspondence in which they identify that they have been assisted in their writing by something as commonplace as a spellchecker on their computer. Once again, in these forms of OCD, there is a combination of the anxiety due to not knowing whether one has stepped across the line in their morals or legal standards, and the guilt of having violated the law, violated innocent others, or God’s will. In developing a treatment package, these issues give rise to the potential that a patient not find it easy to differentiate between their anxious minds compelling threats, and their own potential rigid and high moral standard.
This form of OCD has the potential, more so than others, to involve what is called Overvalued Ideation. Typically patients suffering from OCD are logically aware that the threats that they encounter are irrational and unlikely. This dichotomy of thought, where on one hand they feel compelled to perform a ritual, and on the other hand are aware that the originating threat is irrational, produces a great deal of turmoil.
With Scrupulosity, there is an increased risk that the patient is not fully aware in a logical way that the threat is of an irrational nature. Its as if the disorder has taken over the part of the mind from irrational thought.
The tendency to overvalue the irrational threats and consider them logical and justified can diminish the prognosis of treatment success.
For that patient with scrupulosity OCD, a more intense risk is perceived during the course of treatment. This risk involves not only their well being, but also the risk of disapproval from God. This perceived heightened risk tends to produce a greater level of resistance from the patient to perform the exposure exercise, which is a necessary part of treatment. These exposure exercises must be approached in an aggressive, determined manner, in order for clinical outcomes to be positive.
Although medication is a very powerful frontline treatment for Obsessive Compulsive Disorder, it can sometimes have limited benefit for persons with Scrupulosity when the existence of this overvalued ideation is present.
The treatment course for overvalued Scrupulosity does not deviate significantly from other types of OCD. Generally, a hierarchy is constructed, in which persons gradually are exposed to gradually accelerating levels of risk. This involves increasing levels of risk that their character might be negatively judged. Exposure exercises at the lower level might entail things like a person sampling a grape at a deli, and 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 taking off a very small piece of paper, and littering on the street. An example of a more middle range exposure could involve a patient repeating to him or herself through the day, that the Virgin Mary might not have been a virgin.
Because this form of OCD involves the dual-barrel threat of anxiety, plus character indictment, it is often recommended that a patient receive some exposure to the more philosophical cognitive principles that disputes 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. Due to this, 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 goodness of character. Instead, patients are encouraged to see that their behaviors can vary, and that ones sense of overall self is best off being accepting, rather than evaluating.
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 which encourage people to become good or better persons. These ideas create a greater susceptibility for ones ego or stature to be harmed or diminished.
It is not unusual that professionals within the religious community, such as priests, rabbis and ministers, are 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, so that 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, which produces “seemingly” devout behavior that is really unrelated to the genuine degree of devotion to religious principles.
It is not uncommon that persons are referred for therapy by significant others, or those within the clergy, due to the tendency for those with Scrupulosity to not perceive their excessive behavior as being dysfunctional.
Some Final Thoughts.
It is of the outmost importance that therapy be directed towards increasing the client's tolerance of ambiguity and ability to increase the level of risk taken in relation to OCD. Clinical work can focus on assisting the client towards developing a greater tolerance of discomfort associated with the anxiety and guilt. It is being willing to tolerate such discomfort that leads to recovery. It is also paramount to understand that the goal of therapy is not to have the painful associations go away, but rather to look upon them as challenges to manage. This is one of the most difficult concepts for the patient to grasp with since most people who come to therapy believe that their problem is that they have the thoughts, rather than not managing the anxiety arising as a function of the thoughts, in a way which is adaptive.
It is critical to remember that with OCD, attempting to escape the anxiety or guilt produces the greatest damage psychologically. The thoughts themselves, while unpleasant, are survivable, where the attempt to escape is endless. It is the escape attempt that distorts the sufferer's behavior and adversely affects his or her ability to function in the world. Not being willing to face the spikes, sets the individual up for further attacks of the disorder.
On an encouraging note, once a client makes the decision to resist the spike, it is likely that the discomfort will dissipate within a fairly brief period of time, often 10-20 minutes at most. Those who have just begun therapy sometimes find this hard to believe. Fresh in their memories are images of hours, and sometimes days, spent agonizing over some spike, or getting a ritual right.
Through time, patients become aware that it is their ambivalence and uncertainty about whether or not to give in or not to a spike that produces the prolonged agony. As long as one waiver in the decision to resist, the mind is encouraged to produce more prompts of anxiety and guilt. Similarly, it is not helpful once within the throws of the disorder, for an individual to make a decision to resist giving in and then spend their time monitoring their anxiety and waiting for it to subside. That, too, increases the probability that the disorder will continue to create prompts as spikes. Checking to see if the discomfort is still there keeps the connection open to the anxiety and guilt producing thoughts. Ultimately, the goal of therapy is to see that both the disruptive thoughts and the anxiety are irrelevant. This can be achieved through altering ones mindset, and behavior with respect to these experiments.
Although some behavioral exercises might seem extreme, recovery is facilitated when the patient performs these exercises in a way which is aggressive and conscientious. It is encouraged that clients overcompensate in regard to homework assignments, which is opposite to the demands of the disorder. I've often used the “Bent Pole” analogy in explaining this to clients. In order to straighten a metal pole that has been bent in one direction, you must bend it back to an equal degree in the opposite direction. Over simplified as this analogy is, it expresses the underlying principle related to the rationale for the extremity of these exercises.
By not only disregarding the disorders demands, but taking the extra step of upping the ante or challenging it even further, clients can most effectively regain their equilibrium, the freedom, and obtain comfort in performing the routine tests of daily living of which they have be deprived by the disorder. The disorder deprives people of the aforementioned and treatment can help them obtain those back.
In conclusion, the factor that distinguishes someone who is simply conscientious or concerned, from one with Responsibility OC or Scrupulosity, is the amount of anxiety and/or guilt that she/he experiences 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 OC, and it might be in your best interest to seek professional help.