Author Topic: Are You Too Religious? OCD: Scrupulosity (Read 4721 times)

_noXiouS_ · « **on:** March 18, 2011, 11:15:42 AM »

There is a disorder, called Scrupulosity, that isn't spiritual at all; it's neuro-biological. A rare, often-misdiagnosed subtype of obsessive compulsive disorder, affecting maybe 180,000 (or 6 percent) of the approximately 3 million Americans suffering from OCD.

Meet Tom, a guy a lot like you. He works hard, makes a good wage, has a girlfriend who loves him. He's a God-fearing man as well. Sound familiar? Here's the difference: His belief in God almost killed him.

The condition Tom describes as "high tide" has a long, if shrouded, history. In the 15th century, San Antonio (Archbishop of Florence) wrote of a malady specific to the faithful, describing "a doubt accompanied by a groundless fear, which afflicts the spirit, and makes it apprehend sin where none exists." Saint Ignatius Loyola, founder of the Jesuit Order, was nearly suicidal with thoughts of spiritual impurity, and attended confession compulsively, fearful he'd not properly repented. Martin Luther was plagued by blasphemous thoughts. As long as there have been devout men, there have been men whose devoutness offered no peace, but only an agony of dread, and obsession, and ritual—a flesh-eating bacteria of the spirit.

But the disorder, called Scrupulosity, isn't spiritual at all; it's neuro-biological. A rare, often-misdiagnosed subtype of obsessive compulsive disorder, affecting maybe 180,000 (or 6 percent) of the approximately 3 million Americans suffering from OCD, according to the Westwood Institute for Anxiety Disorders. But unlike cleaners, who can't wash enough, and checkers, who can't be too careful, scrupulous people can't get good enough. The desire to be properly God-fearing, or morally upright, turns traitor, like a diseased immune system attacking its host.

In an obsessive compulsive's world, obsessions are intrusive thoughts that provoke intense anxieties. Compulsions are rituals performed to release or negate those anxieties. Except they don't. They only reinforce the obsessions. "If you go into a situation and you're anxious, and you do something to protect yourself—a compulsion—what you don't find out is whether in fact the situation is dangerous," says Dr. Jeff Szymanski, Ph.D., president of the International OCD Foundation. "You've told your brain, yeah, I think we might have been in danger."

Sufferers recognize their behavior is irrational. They are prisoners to it. And for the scrupulous, those prison walls are fashioned by their own moral impulses, their very belief systems, religious or otherwise. In fact, a growing body of scientific evidence indicates a neurological overlap between the areas of the brain that underlie OCD obsession and the seat of human morality itself. It's no surprise: Moral emotions (such as guilt and empathy) have evolved with us since our knuckle-dragging days. Absent them, we're a planet of Patrick Batemans from American Psycho. It's a balance we take for granted. But too much of them and we cripple ourselves with judgment. Too much of them and we might find ourselves undeserving of a sip of beer.

Tom's problems started when he first went to elementary school (childhood-onset OCD is predominantly male). Catholic school, which his Methodist parents preferred to the shabby public schools in his small southern hometown. He was diagnosed with separation anxiety in the second grade, but he couldn't tell anyone the reason for his distress: He thought that while he was at school, his parents would die. He couldn't tell anyone, because if he did, they would also die—a classic example of what OCD specialists call "magical thinking." The burden was his. He obsessed about death, couldn't see it dramatized on television.

"Man, that would just send me off," he recalls. "Now I know they were panic attacks. I would start sweating right here." He points to the peak of his hairline. His heart would race. His hearing would fade, like someone turning the volume down on the world. "My thought was, It's not going to be OK. It's not going to be OK. Somebody's going to die. I'm going to die."

He found relief from his anxiety in chapel confirmation classes. "It was a safe place," he says. "Also, it was made very clear what I was to do. You are to stand here. You are to put your hand on this bead, say a Hail Mary, and move it. And so, for the rest of my life..." Tom leaves the thought hanging, but I get it. For the rest of his life, he'd be looking for rituals to soothe those anxieties, to make it okay again. Tit for tat. Obsession compulsion. And when he was old enough to understand that God had some providence over death, he linked, in his little boy's mind, his fear of death to a fear of God. Or rather, a fear of God's judgment. "To some people," he tells me quietly, plucking at his beard, "God is the ultimate love. For me, God became the ultimate displeasure."

There's a fine line between someone who is devout, and someone suffering from Scrupulosity. Szymanski defines the difference like this: "People who enjoy their religious practice find fulfillment and purpose. Scrupulous people are driven by fear. The thinking is, I've committed a sin. I've done something blasphemous. I've done some sort of unforgivable thing toward God and he is now angry with me." Scrupulous compulsions usually involve repetitive prayers, mental pacts with God, or punitive shows of piety. Often, patients can't see the theological forest for the trees: stuck for hours perfecting the Rosary, rather than taking solace from their convictions.

Scrupulosity also manifests as a secular, hyper-morality: the man who is incapable of lying (think: Jim Carey in Liar Liar) on even the smallest scale, or the teenager so terrified of harming another creature that he can't wash his car, for fear of drowning a passing spider. But the more severe cases tend to be the religious ones, where repetitive rituals and institutionalized guilt play into the hands of the disorder. And where intrusive thoughts are blasphemies. "There's a ton of shame with Scrupulosity," says Szymanski. "Because they're thinking these horrible things about God, and if they're thinking them, they must mean them in some horrible way, when in fact it's just a random spitting out from a part of the brain."

Thought Action Fusion, psychologists call it: If I think it, it's as though I did it. This is especially devastating for people of faith, who are often taught that thoughts are equitable to actions. I spoke to one patient who became convinced that he was posessed, after curses against Jesus and pledges to Satan swarmed his mind like wasps. His life collapsed. It's the old pink elephant experiment: Tell yourself not to think about something, soon it's the only thing in your head.

Scrupulous people demand an unattainable level of perfection from themselves. There is no middle ground between righteousness and depravity. And no room for doubt—which of course, fuels tons of it. Szymanski remembers treating an atheist who fell prey to scrupulous obsessions just in case. "In any instance," Dr. Szymanski says, "it isn't about religion. It's about the brain malfunctioning."

The malfunction in Tom's brain, through childhood, resulted in garden variety OCD symptoms: Certain notes on the piano had to be played when he entered or left the house, sinks had to be completely free from water. Then came junior prom, when he found himself in a crowded hotel room, stoned and drunk. Around him, boys in rented tuxedos and girls with teased bangs drank Jack Daniels and smoked weed. A few were huffing paint. Fumes blanketed the air. He'd spent his whole childhood rebelling from school (his GPA wasn't a full number), but he was suddenly disgusted. He thought to himself: I can do better than this. "I attributed that to God speaking to me," he says. "It was a calling." Researchers note a spike in OCD symptoms in late adolescence or early adulthood. Tom was right on target.

After that, he had to read a certain number of Bible verses every morning, sitting in a particular spot, one leg propped on a shelf. The verses became a chapter, and the chapter became a book, which could take over an hour to finish. His legs would fall asleep while he read, cramped in that unnatural position. He developed a prayer he had to recite before bed, which got longer and longer, until he needed hours to complete it. If he fell asleep during the prayer, he had to finish it the next morning, before his reading. If he made a mistake, he had to start over. "I had to give the day to God," he tells me. I ask him what he thought would happen back then if he didn't complete those rituals. "God would be pissed off," he says, without hesitation. "He'd be after me. He would definitely hate me. All the blessings in my life would fall away." The frightening God from Tom's boyhood—his first scrupulous invention—was back. Penance was required.

Not long ago, treatment for a guy like Tom would have consisted of talk therapy, only worsening his obsessions. In fact, there remains so much ignorance about Scrupulosity—and OCD in general—that lots of people endure years of unhelpful treatment. Not to mention bad advice. (Researching for this story, I stumbled on a Web health forum, where a Christian woman wrote complaining of intrusive thoughts like I hate God. And every response encouraged her to pray, to redouble her commitment to the church, to rebuke the devil.) Right now, Scrupulosity isn't even listed in the Diagnostic and Statistical Manual of Mental Disorders. Therapists familiar with OCD might not recognize it when they see it.

Leslie Shapiro, a petite, bird-like woman, is a behavioral therapist specializing in Scrupulosity at the Obsessive Compulsive Disorder Institute at McLean Hospital, one of only three residential treatment centers for OCD in the country. The institute's 30 beds are filled with severe, treatment-resistant patients. They come here, to Belmont, Massachusetts, from all over the world. There is a 4-month waiting list. Leslie runs the Scrupulosity Group (composed of three patients when we spoke). And she believes there's another reason scrupulous patients slip between the cracks. "Many therapists are biased against religion," she says, sitting in her office at the institute's top floor. Behind her is a bookshelf packed with tomes on psychology, OCD, and religion. "There's a lot of judgment. It's counter-transference—that's psycho-babble for bringing your own baggage into the room." Dismissed as over-zealous nuts outside their religious communities, and primed with ritual inside them, these people often have nowhere to turn. Shapiro considers treating religious Scrupulosity an obligation. "It's a neurobiological disorder," she says. "It's nobody's fault. Nobody made it happen."

For all subtypes of OCD, treatment is the same: an SSRI (selective serotonin reuptake inhibitor, the same class of drugs prescribed for depression) combined with exposure and response therapy. When patients ritualize to combat anxiety, they only prove to themselves that their obsessions are real, that rituals protect them, reinforcing the OCD feedback loop. During exposure therapy, a patient endures an obsession without performing compulsions, anxiety skyrocketing, until the brain realizes that there is no real danger. "The goal is habituation," Shapiro says. "When you face your obsessive fear and let the anxiety run its course, you habituate to that situation." It's a painful process—especially so for scrupulous patients, since the treatment forces them to repeat their private blasphemies aloud, piling imaginary sin on sin. Therapists use religious counsel to reassure patients (though, I'm told, many wind up doubting their religious counsel, too).

Shapiro introduces me to Ann, a middle-aged Catholic woman, suicidal before she arrived at the Institute just four weeks before, wracked with feelings of sin and unworthiness. Her hairless forearms are red and scraped, from years of compulsive washing and praying. Ann shows me her current exposure treatment, the reverse of a compulsive prayer that has dominated her life for years. She holds up three pages of yellow notebook paper, covered front to back with the following sentence: Oh God, please don't help me. At first, just writing those words caused anxiety attacks. Slowly, she's starting to realize that her Scrupulosity is not interchangeable with her piety.

But while a person obsessed with germs can be taught, definitively, that a doorknob is safe, a person convinced he's damned will never know for sure. Not in this life. The awful doubt remains.

Tom's doubts chased him to college. And while other college kids were doing what college kids do—partying, meeting girls—Tom suppresed all sexual impulses. He remained a virgin until he was 28, and for a three-year period, the only orgasms he had were in his sleep. He did find a girlfriend, another Christian, whose own private demons kept her physically shut down. They enabled each other's anxieties. Meanwhile, Tom deteriorated. "I was losing the ability to do things in my life," he says. "The obvious stuff, like sex, alcohol, stuff like that. Any pleasure. And pretty soon, I couldn't eat. At all. I couldn't even drink."

By May 1999, Tom, 6-foot tall, had withered to 90 pounds. Skin shrink-wrapped to bones. He didn't deserve to eat while others starved. It was wrong. The only thing that felt right was to take up less space. To diminish.

"You were dying," I tell him.

"At that point," he says flatly, "I didn't care."

He was overcome with nervous tics: gulping, clicking his throat, rolling his head around on his neck. It was wrong to work, to move. And wrong to explain. These were God's prescriptions. Asking for help was tantamount to betraying God.

When his parents—alerted to his condition by his desperate girlfriend—brought him back to their house, he hadn't showered in weeks. He smelled like an animal. They took his filthy clothes to wash, and Tom collapsed on a pastel couch in their living room, where he lay for days, in his boxers, staring out of empty eyes. He listened to hushed voices discussing his condition. His mother's movements in the kitchen filled him with dread: mealtimes meant food. She brought him saltines, and Tom might take two hours to chew and swallow a cracker. At one point, she tried to force one through his closed lips. He kept his teeth clenched.

His first psychiatric evaluation, Tom was tested to assess the severity of his obsessions. "Congratulations," said the doctor. "You got a perfect score."
Moral crises like the one Tom describes have traditionally been the provenence of clergy and philosophers. That's changing. Neurologists have discovered that morals, and moral emotions, are not just abstract concepts, but coded in specific regions of the brain. Harvard psychology professor Joshua Greene, with help from a fMRI scanner, collected data from brains considering an old two-part philosophical quandary. First, would you pull a lever to reroute an unstoppable train from a track with five workers standing on it to a track with only one? Overwhelmingly, people say they would. Second, would you push a man into the tracks of the oncoming train to save the five workers? Overwhelming, people would not, even though the math—kill one guy, save five—is the same. Greene found that the two questions trigger different regions in the brain. The first activates the dorsolateral prefrontal cortex, behind the brow, partly responsible for reasoning and problem solving. The second activates areas known to regulate empathy and social cognition.

Researchers like Greene suggest that these two regions duke it out in any moral situation. If you've ever felt like you were wrestling with yourself over the "right" thing to do, you probably were. And a powerful emotional response drowns out logic when confronted with primal notions of right and wrong (don't push people into trains). This idea is further supported by evidence that people with damage to the medial prefrontral cortex—emotion's advocate—have no problem pushing the guy, suffocating the crying baby to save hiding villagers, sacrificing one hostage for the rest (pick your hypothetical). The numbers add up, but the acts are repulsive to most of us. We need both subsystems talking to each other for our moral compasses to find true north. To extrapolate a bit, hyperactivity in either might be as debilitating as no activity at all.

Author Topic: Are You Too Religious? OCD: Scrupulosity (Read 4721 times)

_noXiouS_

Are You Too Religious? OCD: Scrupulosity

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