A Summary and Response to Scrupulosity in Patients with OCD published in Journal of Anxiety Disorders

Introduction

Obsessive-Compulsive Disorder (OCD) is a nasty beast. I find the scrupulous (religious) elements the most ugly b/c unlike the general OCD symptoms I have a much harder time distinguishing which are “legitimate” and which are “illegitimate.” That is, my brain is being ridiculous when I feel the need to wash my hands over and over again…I have a much harder time knowing if my brain is being ridiculous when it constantly urges me to spend more time with God.

Person washing his hands

Person washing his hands (Photo credit: Wikipedia)

I already take medication for OCD – and it helps significantly. I don’t wash my hands too much, turn my car around to check if maybe I accidentally ran someone over without noticing, or so on any more (okay, so I do regularly check thoroughly via my mirrors after backing out of my driveway…), but the scrupulous symptoms, while less intense (they nearly crippled me), are still present.

I have spent significant time in counseling and see a Cognitive Behavioral Therapist currently. I’ve read many books and articles on the topic and am oftentimes one folks who are struggling with OCD or scrupulosity will engage in conversation for assistance.

Lately I’ve been feeling the pressure of the scrupulous more thoroughly and have been trying to battle it off. Part of this includes reading about OCD. Learning about OCD helps soothe me and also gives me ideas for new methods of battling my OCD. In this case I read Elizabeth A. Nelson, Jonathan S. Abramowitz, Stephen P. Whiteside, and Brett J. Deacon’s article “Scrupulosity in Patients with Obsessive-Compulsive Disorder: Relationship to Clinical and Cognitive Phenomena.” (Journal of Anxiety Disorders, 2006, pp. 1071-1086).

It is a fairly technical article and I am not trained in statistics and other forms of research analysis, so some portions of the report where undecipherable to me…but I figured I’d share what I was able to distill from the report along with my commentary when I had such.

Summary and Response

  • “The themes of OCD vary widely…with one of the more recalcitrant presentations involving obsessions and compulsions concerned with religion…” – pg. 1072.
    • I’m glad to hear it isn’t just inside my head that scrupulosity is difficult to treat.
  • “Religious OCD symptoms…typically involve ‘seeing sin where there is none’ and are frequently focused on minor details of the person’s religion, to the exclusion of more important areas.” – pg. 1072.
    • I think I am much better at this now than previously, but it is very easy to get tied up in small details and anxiety which prevents one from loving others. The principle that I am to love to the maximum has been helpful to me in setting aside anxiety and being willing to wade into situations where I know I will fail (sin).[1]
  • “Examining the content of obsessions among 425 individuals with OCD, Foa and Kozak (1995) found religion to be the fifth most common theme, with 5.9% of patients endorsing it as a primary obsessional symptom. Antony, Downie, and Swinson (1998) found that 24.2% of a sample of 182 adults and adolescents with OCD reported obsessions having to do with religion (not necessarily their primary obsession).” – pg. 1072.
  • “Previous research suggests that a patient’s religious denomination and strength of religiosity can influence his or her OCD symptoms…and clinical observations indicate that scrupulosity is often inadvertently reinforced by the teachings of the individuals religion.” – pg. 1072.
    • I have found this to be true in my own experience. When I have been in settings which emphasize my part, my symptoms flare up exceedingly whereas settings which emphasize God’s sovereignty and grace oftentimes relieve symptoms.
    • I read grace books on an almost continuous basis (e.g. Rutland, Lucado), as I have a tendency to quickly fall back into performance mode.
  • “Scrupulosity, with a focus on morality, is also mentioned in DSM-IV-TR as a symptom of obsessive-compulsive personality disorder (OCPD). However, whereas the thoughts and doubts pertaining to morality are experienced as unwanted and unwelcome (i.e., ‘ego-dystonic’) in OCD, they are experienced as consistent with the person’s world view (i.e., ‘ego-sytonic’) in OCPD…In contrast, the scrupulous ideation in OCPD (a) does not evoke anxiety or fear, (b) is not subjectively resisted, and (c) is not associated with violent and sexual obsessions.” – pg. 1072.
    • This is a footnote at the bottom of the page, but I disagree with it. I would suggest that individuals with OCPD, at least in my limited experience, may not be internally aware of their distress, but are in fact suffering significant distress. I think I could have been classified at one juncture as OCPD but at some definite point in time (during my college years) I experienced a ‘breakthrough’ which provided insight into the underlying anxiety and control, allowing me to become ‘OCD’ rather than ‘OCPD.’ The older one becomes with OCPD, the less possible I imagine it is to transition into OCD, b/c it involves admitting that much of what one has done and said over the last x number of years was of no or negative consequence. I was young and did not have much to look back on and admit was a wash.
  • “Contemporary cognitive-behavioral models of OCD implicate specific cognitive phenomena in the development and maintenance of the disorder. These cognitions include: (a) overestimation of threat (the belief that negative events are especially likely and would be especially awful); (b) inflated responsibility (the belief that one has the power to cause, and/or the duty to prevent, negative outcomes); (c) overimportance of intrusive thoughts (the belief that the mere presence of a thought indicates that the thought is significant); (d) the need to control intrusive thoughts (the belief that complete control over one’s mental processes is both necessary and possible); (e) perfectionism (the belief that mistakes and imperfection are intolerable); and (f) intolerance of uncertainty (the idea that it is important to be 100% certain that negative outcomes will not occur (Frost & Steketee, 2002).” – pg. 1073.
  • ” The essential tenet of cognitive-behavioral models…is that OCD develops when unpleasant, yet harmless, intrusive thoughts, doubts, impulses, and images are misinterpreted along the lines of the cognitive factors described above. This misappraisal evokes anxiety and motivates efforts to reduce this anxiety via neutralizing behavior (e.g., rituals) which is reinforced by the immediate (albeit temporary) reduction in distress it engenders…” – pg. 1073.
  • They used a number of different tools to analyze symptom severity, etc. Some I was familiar with, some I’d like to look into further. These included the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Obsessive-Compulsive Inventory Revised (OCI-R), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory-Trait version, Form Y (STAI-T), Penn Inventory of Scrupulosity (PIOS), Interpretation of Intrusions Inventory (III), Intolerance of Uncertainty Scale (IUS), and Mini International Neuropsychiatric Interview (MINI).
  • “Post hoc comparisons…revealed that Protestant patients…scored significantly higher on the PIOS than did patients with no religious affiliation…but not significantly higher…than did Catholic patients…” – pg. 1079.
  • “When we computed similar correlations for Catholic and Protestant patients separately, we found no significant relationships between PIOS score and strength of religious devotion in either of these groups.” – pg. 1079.
    • Essentially, one’s religious fervency is not correlated with the intensity of the symptoms, if I am understanding this correctly. Thus an individual barely committed to Christianity and an individual with a strong, life-long commitment may experience similar symptoms with similar severity. I would consider this a significant indicator for underlying biological/chemical/neurological processes (something which isn’t at issue here, but which is still a topic of discussion within Christian counseling circles).
  • “As expected, the OCI-R obsessing subscale significantly predicted scores on the PIOS.” – pg. 1080.
    • If I understand this correctly, one can predict scores regarding scrupulosity significantly using a more general OCD inventory that evaluates the obsessive nature of an individuals OCD.”
  • “Our data indicate that scrupulosity symptoms are present in each presentation of OCD. Although, as expected, patients suffering primarily with severe unacceptable obsessional thoughts (i.e., religious, violent, and sexual obsessions) evidenced greater levels of scrupulosity compared to those with primary contamination symptoms.” –  pg. 1081.
    • I’d like some clarification on the first sentence above. Are the authors saying that every individual with OCD has some scrupulosity or that for each type of OCD symptoms (e.g. hand washing versus counting) there are examples of individuals with scrupulous behavior – I tend to think the latter.
  • “Thus, even if religious obsessions are not associated with especially high frequency, interference in functioning, difficulty with resistance or control (i.e., the symptom parameters assessed by the Y-BOCS), these phenomena might represent a particularly distressing presentation of OCD.” – pg. 1082.
    • If I’m understanding this correctly, the frequency with which obsessions occur are not more with scrupulosity than seen in OCD generally, but they can be much more distressing to the sufferer than general OCD. I would agree with this.
  • “In support of our second hypothesis, scrupulosity was moderately associated with multiple cognitive biases believed to underlie the development of obsessional symptoms, including moral TAF, overestimates of the importance of and need to control intrusive thoughts, and inflated perceptions of responsibility.” – pg. 1082.
    • In other words, scrupulous sufferers are more likely to have poor cognitive patterns regarding the reality of their responsibility for their thoughts but they do not suffer (more frequently) poor cognitive patterns regarding the power of their thoughts to injure others.
  • “In an effort to reduce obsessional distress, individuals engage in compulsive (neutralizing) behaviors such as excessive prayer, confession, and checking for reassurance from religious authorities, among other strategies.” – pg. 1083.
  • “Research indicates that exposure and response prevention (ERP) is the most effective treatment for OCD (Kozak & Coles, 2005a), although many OCD patients with scrupulosity have difficulty accepting and adhering to ERP because it involves directly confronting situations and thoughts that are perceived to be sinful.” – pg. 1083.
    • Yup, that is a real problem…
  • “Nevertheless, we speculate that some CT techniques have relevance for facilitating ERP in cases of scrupulosity. For instance, patients could be taught that everyone sometimes experiences unwanted (morally repugnant) thoughts. The therapist could also arrange a meeting between the patient and a clergy member to disconfirm the idea that the occurrence of intrusive and unwanted thoughts (as opposed to deliberately thinking such thoughts) is equivalent to committing sinful behavior.” – pg. 1083-4.
    • I’d agree with this. Normalizing intrusive thoughts is important and helping an individual understand the difference between undesired and intentional immoral thoughts is also important.
    • I think that these unwanted thoughts are still ‘sin’ – but I would suggest that they are outside the control of the individual within this lifetime. An emphasis should be placed on the generosity of God’s grace and the petty God one creates when beating oneself up for unwanted thoughts.
  • The authors seem to suggest that ERP is still a way forward, once cognitive training has occurred (pg. 1084). I agree that ERP is an option, but I’m concerned about whether there is enough of an understanding of the importance of not overriding the morals of the individual in an attempt to cure – e.g. showing an individual who struggles with impure sexual thoughts pornography. This is an unacceptable solution within the faith community. We need another way forward…and energies placed into ERP that requires an individual to compromise on legitimate moral beliefs will not be that way.

Concluding Thoughts

I’m thankful to Nelson, Abramowitz, Whiteside, and Deacon for their careful research on scrupulosity. I applaud their commitment and dedication.

I’m thinking about (and hoping others suffering scrupulosity will do the same) what sort of therapeutic process could be utilized to treat scrupulosity that would not involve ERP procedures that would encourage actions considered immoral by the faith community.[2]

A few ways in which I have attempted to battle scrupulosity without engaging in this form of ERP therapy is:

  • Looking for my “secular” OCD and battling that. e.g., focusing on my vocal ticks (still have ’em), checking doors, and looking for people I ran over. Since they are all driven by the same underlying brain processes, I figure working on one should help relieve others…
  • Reading constantly a diet of materials which counter my brain’s natural ways of thinking and which encourage me to understand God as bigger and more important than me – items which while affirmed by the scrupulous oftentimes fail to take root in our hearts (at least in mine).
  1. [1]I can be quite a good person by myself, but being around human beings is difficult. :) At times I would isolate myself to avoid sinning.
  2. [2]In other words, even if the individual accepts the procedures as necessary, I think this is not a road forward, as the larger faith community cannot approve of these measures.

4 Responses

  1. Margaret says:

    Very interesting article. I wonder about this statement, though…”I think that these unwanted thoughts are still ‘sin’ – but I would suggest that they are outside the control of the individual within this lifetime.” It seems to me that things outside our control are not sin…I would place them more in the category of temptation…temptations come, but by not acting on them we avoid the sin…thoughts come, but by not dwelling on them or acting on them, we avoid the sin. I especially like this statement “An emphasis should be placed on the generosity of God’s grace and the petty God one creates when beating oneself up for unwanted thoughts.” I also like this – “The principle that I am to love to the maximum has been helpful to me in setting aside anxiety and being willing to wade into situations where I know I will fail (sin).” – and it’s foot note! But again I question, is failing sin? or is it failing? I think the key is focusing on love, like you said…The speaker at Eastern University yesterday said “Show up and see what God does.” In other words, be available to be used by God in whatever situation we find ourselves in…be willing vessels to carry His love and grace to people and He will use that willingness to accomplish His will and His good through us.

    I appreciate your comments and have shared some of your struggles. It is so good to be learning of God’s mercy, love and grace. He really is not a petty God! And its pretty hard to be used when we are bruised and bleeding from those self beatings!

    Thank you again for sharing this.

  2. Paul Mackey says:

    Hey Dave,

    I don’t know whether I suffer from OCD or not, but I know that I have struggled a great deal with overwhelming feelings of guilt related to my relationship with God. These feelings have not been fuel for growing my passion for loving God and others, nor have they been instruments that pushed me closer to God in and of themselves. Rather, I have found that it has been by, as you have mentioned, meditating upon the grace and greatness of God that I have found freedom from the grips of these overwhelming waves of guilt.

    Essentially, I have found that these overwhelming feelings of guilt are self-focused, and self-absorbed. The thoughts revolve around my desire to be of value and significance rather than around my desire to love God and others. At times I do find that the burden of guilt I feel is indeed rooted in broken-heartedness over my lack of love for God and others, but this is the exception rather than the norm.

    In his book, “The Prodigal God”, Timothy Keller shares a thought that has been hugely beneficial to me in this area. Essentially, he says that we try so hard to be good enough for God to owe us something, and then when we make a mistake, we try equally hard to deserve His forgiveness. In neither instance are we understanding that grace is freely given to us, and so in neither case are we enjoying the freedom that His forgiveness and love offers. I am far too often guilty of trying to earn His forgiveness.

    I am more aware now of how desperately wicked my heart is than I have ever been before, and yet at the same time, I care much less about it. By that I do not mean that I am unconcerned with sinning, but that I have found the far greater call of the Christian life is to know God and make Him known. Rather than constantly wondering how I appear, and how I look to God and the world around me, I seek to love God and others, accepting that I am broken and sinful, but He is great enough and gracious enough to love me and others through me regardless. So, though I am constantly tempted to focus on my guilt and sin, recognizing the unconditional love of God, I am able to move forward with eyes focused on Him and others, rather than focused on my sin.

    Like I said, I do not know whether I have OCD or not, and am sure others struggle far more with overwhelming feelings of guilt than I do. I don’t know what treatments are most appropriate for treating these struggles, but I know that a deeper understanding of God’s grace, and the realization that my tendency to focus on my guilt is rooted in too much concern with myself, rather than with God and others, has been tremendously beneficial in helping me not get pulled down into helpless depression by my sin. Guilt, real or perceived is forgiven and assuaged by Christ’s death on the cross, and the freedom and power to love is secured in the power of His resurrection.

    As always, thanks for your honesty and willingness to share what you are learning.

    Paul Mackey

    • davemackey says:

      Thanks Paul for your response – great thoughts. I’m not qualified to make diagnoses, I would just say that mental health is a spectrum. This is why many people say, “Ohh, I think maybe I’m a little obsessive-compulsive.” But that is within the normal scale of functioning. One is suffering from a mental disorder (e.g. OCD/scrupulosity) when it interferes with your normal functioning – e.g., if it impairs your ability to work, interact with your wife or friends, etc. The more significant the impairment, the more severe the disorder. Here is a brief OCD self-test to see if you have red flags for OCD: http://psychcentral.com/ocdquiz.htm. I’d note, however, that individuals who struggle with scrupulosity may not demonstrate all the normal OCD flags, and thus could appear as “being healthy” when actually struggling with scrupulosity. I’m not aware of a self-test for scrupulosity publicly available.

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