Scrupulosity

This article is about pathological guilt over religious or moral issues. For related terms, see Scruples (disambiguation).

Scrupulosity is a psychological disorder characterized by pathological guilt about moral or religious issues. It is personally distressing, objectively dysfunctional, and often accompanied by significant impairment in social functioning.^[1] It is typically conceptualized as a moral or religious form of obsessive–compulsive disorder (OCD),^[2] although this categorization is empirically disputable.^[1]

The term is derived from the Latin scrupulum, a sharp stone, implying a stabbing pain on the conscience.^[1] Scrupulosity was formerly called scruples in religious contexts, but the word scruples now commonly refers to a troubling of the conscience rather than to the disorder.

As a personality trait, scrupulosity is a recognized diagnostic criterion for obsessive–compulsive personality disorder.^[3] It is sometimes called "scrupulousness," but that word properly applies to the positive trait of having scruples.

History

John Moore (shown c. 1691–1703) was the first to describe the disorder, calling it "religious melancholy".^[4]

Scrupulosity is the modern-day medical diagnosis that corresponds to a traditional use of the term scruples in a religious context, e.g., by Roman Catholics, to mean obsessive concern with one's own sins and compulsive performance of religious devotion.^[5] This use of the term dates to the 12th century.^[6] Several historical and religious figures suffered from doubts of sin, and expressed their pains. Ignatius of Loyola, founder of the Jesuits, wrote "After I have trodden upon a cross formed by two straws, ... there comes to me from without a thought that I have sinned; ... this is probably a scruple and temptation suggested by the enemy."^[7] Alphonsus Liguori, the Redemptorists' founder, wrote of it as "groundless fear of sinning that arises from 'erroneous ideas'".^[6] Although the condition was lifelong for Loyola and Liguori,^[8][9] Thérèse of Lisieux stated that she recovered from her condition after 18 months, writing "One would have to pass through this martyrdom to understand it well, and for me to express what I experienced for a year and a half would be impossible."^[10] Martin Luther also suffered from obsessive doubts; in his mind, his omitting the word enim ("for") during the Eucharist was as horrible as laziness, divorce, or murdering one's parent.^[11]

Although historical religious figures such as Loyola, Luther and John Bunyan are commonly cited as examples of scrupulosity in modern self-help books, some of these retrospective diagnoses may be deeply ahistorical: these figures' obsession with salvation may have been excessive by modern standards, but that does not mean that it was pathological.^[12]

Scrupulosity's first known public description as a disorder was in 1691, by John Moore, who called it "religious melancholy" and said it made people "fear, that what they do, is so defective and unfit to be presented unto God, that he will not accept it".^[4] Loyola, Liguori, the French confessor R.P. Duguet, and other religious authorities and figures attempted to develop solutions and coping mechanisms;^[1] the monthly newsletter Scrupulous Anonymous, published by the followers of Liguori, has been used as an adjunct to therapy.^[13] In the 19th century, Christian spiritual advisors in the U.S. and Britain became worried that scrupulosity was not only a sin in itself, but also led to sin, by attacking the virtues of faith, hope, and charity. Studies in the mid-20th century reported that scrupulosity was a major problem among American Catholics, with up to 25% of high school students affected; commentators at the time asserted that this was an increase over previous levels.^[14]

Starting in the 20th century, individuals with scrupulosity in the U.S. and Britain increasingly began looking to psychiatrists, rather than to religious advisors, for help with their disorder.^[14]

Characteristics

In scrupulosity, a person's obsessions focus on moral or religious fears, such as the fear of being an evil person or the fear of divine retribution for sin. Although it can affect nonreligious people, it is usually related to religious beliefs. In the strict sense, not all obsessive–compulsive behaviors related to religion are instances of scrupulosity: strictly speaking, for example, scrupulosity is not present in people who repeat religious requirements merely to be sure that they were done properly.^[15]

Treatment

Treatment is similar to that for other forms of obsessive–compulsive disorder.^[16] Typical treatments for OCD seem to be relatively ineffective for scrupulosity, or may require special considerations. Little overall support exists for any of the several possibly-effective treatment approaches.^[1]

Exposure and response prevention (ERP), a form of behavior therapy, is widely used for OCD in general and may be promising for scrupulosity in particular.^[1] ERP is based on the idea that deliberate repeated exposure to obsessional stimuli lessens anxiety, and that avoiding rituals lowers the urge to behave compulsively. For example, with ERP a person obsessed by blasphemous thoughts while reading the Bible would practice reading the Bible.^[16] However, ERP is considerably harder to implement than with other disorders, because scrupulosity often involves spiritual issues that are not specific situations and objects. For example, ERP is not appropriate for a man obsessed by feelings that God has rejected and is punishing him. Cognitive therapy may be appropriate when ERP is not feasible.^[1] Other therapy strategies include noting contradictions between the compulsive behaviors and moral or religious teachings, and informing individuals that for centuries religious figures have suggested strategies similar to ERP (see History).^[16] Religious counseling may be an additional way to readjust beliefs associated with the disorder, though it may also stimulate greater anxiety.^[1]

Little evidence is available on the use of medications to treat scrupulosity.^[1] Although serotonergic medications are often used to treat OCD,^[16] studies of pharmacologic treatment of scrupulosity in particular have produced so few results that even tentative recommendations cannot be made.^[1]

Treatment of scrupulosity in children has not been investigated to the extent it has been studied in adults, and one of the factors that makes the treatment difficult is the fine line the therapist must walk between engaging and offending the client.^[17]

Epidemiology

The prevalence of scrupulosity is speculative; available data do not permit reliable estimates, and available analysis mostly disregard associations with age or with gender, and have not reliably addressed associations with geography or ethnicity.^[1] Available data suggest that the prevalence of obsessive–compulsive disorder does not differ by culture, except where prevalence rates differ for all psychiatric disorders. No association between OCD and depth of religious beliefs has been demonstrated, although data are scarce.^[15] There are large regional differences in the percentage of OCD patients who have religious obsessions or compulsions, ranging from 0-7% in countries like the U.K. and Singapore, to 40-60% in traditional Muslim and orthodox Jewish populations.^[7]

References

1. ^ ^{a b c d e f g h i j k} Miller CH, Hedges DW. Scrupulosity disorder: an overview and introductory analysis. J Anxiety Disord. 2008;22(6):1042–58. doi:10.1016/j.janxdis.2007.11.004. PMID 18226490.
2. ^ Deacon B, Nelson EA. On the nature and treatment of scrupulosity [PDF]. Pragmatic Case Stud Psychother. 2008;4(2):39–53.
3. ^ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th, text revision (DSM-IV-TR) ed. 2000. ISBN 0890420254. Diagnostic criteria for 301.4 Obsessive–compulsive personality disorder.
4. ^ ^{a b} López-Ibor JJ Jr, López-Ibor Alcocer MI. Religious experience and psychopathology [PDF]. In: Verhagen P, Van Praag HM, López-Ibor JJ Jr, Cox J, Moussaoui D, editors. Religion and Psychiatry: Beyond Boundaries. Wiley; 2010. ISBN 978-0-470-69471-8. p. 211–33.
5. ^ Ciarrocchi JW. The Doubting Disease: Help for Scrupulosity and Religious Compulsions. Mahwah, NJ: Paulist Press; 1995. ISBN 0-8091-3553-1. Scruples: common and uncommon. p. 32–47.
6. ^ ^{a b} Taylor CZ. Religious addiction: obsession with spirituality. Pastoral Psych. 2002;50(4):291–315. doi:10.1023/A:1014074130084.
7. ^ ^{a b} van Megen HJGM, den Boer-Wolters D, Verhagen PJ. Obsessive compulsive disorder and religion: a reconnaissance. In: Verhagen P, Van Praag HM, López-Ibor JJ Jr, Cox J, Moussaoui D, editors. Religion and Psychiatry: Beyond Boundaries. Wiley; 2010. ISBN 978-0-470-69471-8. p. 271–82.
8. ^ Rose S. St. Ignatius Loyola And The Early Jesuits. 2007. ISBN 1408622556. Manresa—the spiritual exercises—1523. p. 45–71.
9. ^ Alphonsus de Liguori. Peace for scrupulous souls. In: Jones FM, editor and translator. Selected Writings. Mahwah, NJ: Paulist Press; 1999. ISBN 0-8091-3771-2. p. 209–18.
10. ^ Monahan J. Thérèse of Lisieux. Paulist Press; 2003. ISBN 0809167107. p. 45.
11. ^ Aho JA. Confession and Bookkeeping: the Religious, Moral, and Rhetorical Roots of Modern Accounting. Albany: State University of New York Press; 2005. ISBN 0-7914-6545-4. Martin Luther and scrupulosity. p. 95–8.
12. ^ Cefalu P. The doubting disease: religious scrupulosity and obsessive–compulsive disorder in historical context. J Med Humanit. 2010. doi:10.1007/s10912-010-9107-3. PMID 20127153.
13. ^ Ciarrocchi. The Doubting Disease. Getting help for scruples and OCD. p. 103–12.
14. ^ ^{a b} Bourke J. Divine madness: the dilemma of religious scruples in twentieth-century America and Britain. J Soc Hist. 2009;42(3):581–603. doi:10.1353/jsh.0.0152.
15. ^ ^{a b} Huppert JD, Siev J, Kushner ES. When religion and obsessive–compulsive disorder collide: treating scrupulosity in Ultra-Orthodox Jews. J Clin Psychol. 2007;63(10):925–41. doi:10.1002/jclp.20404. PMID 17828763.
16. ^ ^{a b c d} Abramowitz JS. Scrupulosity. In: Abramowitz JS, McKay D, Taylor S. Clinical Handbook of Obsessive–Compulsive Disorder and Related Problems. Johns Hopkins University Press; 2008. ISBN 0-8018-8697-X. p. 156–72.
17. ^ McKay D, Storch EA, Nelson B, Morales M, Moretz MW. Obsessive–compulsive disorder in children and adolescents: treating difficult cases. In: McKay D, Storch EA, editors. Cognitive Behavior Therapy for Children: Treating Complex and Refractory Cases. Springer; 2009. ISBN 0-8261-1686-8. p. 81–114.

Further reading

• Beattie, Trent (2011). Scruples and Sainthood.
• Collie R. The Obsessive–Compulsive Disorder: Pastoral Care for the Road to Change. Routledge; 2000. ISBN 078900707X.
• Osborne I. Can Christianity Cure Obsessive–Compulsive Disorder?: A Psychiatrist Explores the Role of Faith in Treatment. Brazos Press; 2008. ISBN 1587432064.
• Santa T. Understanding Scrupulosity. Liguori Publications; 1999. ISBN 0764803735.
• Traig Jennifer. Devil in the Details: Scenes from an Obsessive Girlhood. Back Bay Books; 2006. ISBN 031601074X.
• Van Ornum W. A Thousand Frightening Fantasies: Understanding & Healing Scrupulosity & Obsessive Compulsive Disorder. Crossroad Publishing; 1997. ISBN 0824516052.