Pathological Guilt: a Persistent Yet Overlooked Treatment Factor in Obsessive-Compulsive Disorder

ANNALS OF CLINICAL PSYCHIATRY

ANNALS OF CLINICAL PSYCHIATRY 2011;23(1):63-70 REVIEW ARTICLE

Pathological guilt: A persistent yet overlooked treatment factor in obsessive-compulsive disorder

Leslie J. Shapiro, LICSW BACKGROUND: Guilt appears to be a factor that may increase the severity OCD Institute, McLean Hospital of obsessive-compulsive disorder (OCD) and negatively impact treatment Belmont, MA, USA outcomes. However, researchers and clinicians have paid little attention S. Evelyn Stewart, MD to addressing guilt in OCD treatment. Because guilt is an important per- OCD Institute, McLean Hospital Belmont, MA, USA petuating and mediating factor for OCD symptoms and the development Harvard Medical School of guilt-specific strategies may yield improved treatment outcomes, we Massachusetts General Hospital hypothesized that a review of the relevant literature may provide impor- Boston, MA, USA tant guidance for the field.

METHODS: To identify existing scientific contributions across psychological, biologic, and theological disciplines, we conducted a systematic review of the literature on the topic of pathological guilt (PG) in OCD.

RESULTS: Fourteen studies focusing on both PG and OCD were identified. The content of these papers consistently reflected the theme that guilt plays a significant role in OCD and obsessive-compulsive symptoms.

CONCLUSIONS: The potential influence and moderating effects of guilt require more focused attention in the clinical management of OCD. Devel- opment of routine standardized measures and treatment protocols targeting the role of guilt in OCD, in addition to consultation with clergy or other appropriate community resources, would provide valuable contributions to the literature. Addressing this affective component related to OCD may

CORRESPONDENCE lead to improved treatment outcomes and fewer relapses for this debilitat- Leslie J. Shapiro, LICSW ing and frequently chronic illness. OCD Institute, McLean Hospital 115 Mill Street KEYWORDS: OCD, guilt, state, trait, moral, responsibility Belmont, MA 02478 USA

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INTRODUCTION has been suggested that acting on OCD symptoms often has an intention of avoiding guilt for fear of acting irresponsibly.1 It has been suggested that guilt may negatively impact the Bringing this affective component to awareness during treat- severity and treatment outcome of obsessive-compulsive ment may lead to improved outcomes and fewer relapses for disorder (OCD). Interest in the role of guilt in OCD has this debilitating and frequently chronic illness. recently resurfaced.1-4 Although guilt has been intermit- tently cited as an important mediator of outcome by Classification of guilt OCD investigators,5-9 no clinical treatment protocols have Guilt is a concept that has been examined across multiple been devised to effectively address this factor. It is unclear disciplines, including biologic, psychological, and theologi- whether unaddressed guilt in OCD leads to relapse fol- cal. Evolutionary biology describes guilt as a component of lowing an otherwise effective course of treatment, and/ “reciprocal altruism.” By this definition, guilt is advantageous or if guilt is a responsible component in treatment refrac- as it regulates opportunistic behaviors such as those that toriness of some OCD cases. We hypothesized that guilt is maintain social relationships.20 According to this definition, a significant perpetuating factor for OCD symptoms and guilt is adaptive and protects humans from one another. that development of effective guilt-specific strategies could Guilt also is a factor in other psychiatric disorders. yield improved outcomes. To examine contributions on Major depressive disorder (MDD) includes excessive or this topic across psychological and theological disciplines, inappropriate guilt as a diagnostic affective component, we reviewed the body of relevant literature on guilt in OCD. along with feelings of worthlessness.21 Interestingly, Alex- The heterogeneous symptoms of OCD are well ander et al22 found guilt, but not shame, to be associated described by the Young-Brown Obsessive Compulsive with levels of depression. Scale (Y-BOCS) Symptom Checklist.10 While PG is fre- Guilt also is found in both simple and complex post- quently conceptualized as a major component of OCD traumatic stress disorder (PTSD).23 Hathaway et al24 -related scrupulosity (obsessions that involve religious reported that at emotions of guilt, anger, shame, sadness, and/or moral content),11-19 its impact extends beyond this and numbing occurred more frequently than fear in PTSD. context. From a clinical perspective, guilt may mediate Guilt-based PTSD was recognized as a subtype requir- most other obsessions, including aggressive, contamina- ing specialized treatment strategies25 and trauma-related tion, sexual, religious, symmetry/exactness, and other guilt was associated with increased PTSD symptomatology obsessions. It may also motivate nearly all compulsion through the use of avoidant coping strategies.26 subtypes, including cleaning, checking, repeating, count- In the current review paper, we utilize the inclusive ing, ordering, and miscellaneous compulsions. Although construct of guilt as examined across disciplines and over descriptions of guilt in OCD have been provided with time to explore how it pertains to OCD. Guilt has been respect to scrupulosity patients, it has been largely ignored defined by psychologists, psychiatrists, and clinicians as a in discussion of other OCD subtypes. Rather, a sense of disagreeable emotional condition associated with trans- inflated responsibility has been identified as the primary gression of personal rules, morals, or mores. By this defini- concern regarding the “moral” aspect of obsessions.4 tion, guilt may resolve with reparation, restitution or con- For many patients with OCD, the concern is not that fession, and forgiveness.27 Additional clinical definitions of they will be responsible for the consequences of their obses- guilt have included the following: guilt as an expression of sions; rather, they fear that the obsessive thoughts indicate an self-reproach and remorse for one’s behavior (as if one vio- unintended wish for them to happen. An OCD sufferer might lated a moral principle)28; as a drive that motivates compul- be unaware that he or she is angry with a loved one and may sive responses29; as the resultant dysphoric feeling upon the begin to have intrusive morbid thoughts about that person. realization of violating a personally relevant moral or social For example, an adult daughter may experience underlying standard30; and as chronic self-blame and obsessive rumi- frustration at her mother who continues to be overprotec- nation over some objectionable or harmful behavior.31 In tive. The daughter suddenly has intrusive thoughts about historical psychoanalytic literature Vergote32 stated, “Guilt stabbing her mother while they prepare dinner. With regard and desire, because of their fundamental nature, are the to not-just-right experiences (NJREs), frequent and intense two themes at the heart of religion and psychoanalysis.” guilt feelings and the fear of guilt itself, have been detected In theological and religious literature, the central as an inherent vulnerability in those with OCD.2 Further, it tenet of guilt is associated with “condemnation” related to

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FIGURE to evaluate differential perspectives and recommendations Selection of publications for review regarding this construct across clinical and theological pas- Initiated database toral settings. References from each manuscript were used searches to identify additional manuscripts in an iterative manner. N = 243 N = 131 exclusions (duplicates, psychoanalytic, non- OCD samples, non-English) Further review RESULTS N = 112 N = 56 exclusions Relevant articles were selected from the initial database (unrelated, law papers, non- guilt related) search results according to defined threshold criteria. Man- Potential uscripts meeting the criteria included 10 from PubMed, 7 subsample N = 42 from Academic OneFile, 5 from PsychNet, and 1 from both JSTOR and ATLA. Several of these were identified by ≥1 N = 42 exclusions (case studies, non-related database, such that the total number of identified papers psychological factors) Final review sample for review focusing specifically on guilt and OCD was 14. N = 14 Among these, 11 were clinical research studies (including 2 dissertations, 1 case study, and 1 psychometric measure OCD: obsessive-compulsive disorder. development), 2 were neuroimaging research studies, and 1 was a literature review. Authors, samples sizes, sample a breach of divine precepts or rules, regulations, and laws types, measures, and results for each of these studies are of a particular organized religion or church, which is simi- summarized in the TABLE. lar to psychologically defined guilt.33 In biblical text, the The outcomes of this review on the identification of PG terms guilt and sin are used interchangeably.34 Text from as a clinically important factor in OCD are summarized in the Old Testament identifies guilt as “spiritual and moral the TABLE. Three central themes emerged on the role of guilt failure, toward one’s fellow man or toward God”; as “delib- in OCD, as follows: 1) in nonclinical samples guilt leads erate revolting, rebelling, and transgressing against God”; to obsessive-compulsive (OC)-like symptoms, includ- and as “the being or acting wrongly or pervertedly.”35 Text ing increased threat perception, NJREs, overresponsibil- from the New Testament indicates a shift in attitude about ity, and intrusive thoughts/impulses1,2,37; 2) in nonclinical sin and guilt by declaring real and certain victory over sin. neuroimaging samples, state-guilt leads to brain activation in regions proximal to OCD-affected regions38,39; and 3) in OCD samples, common guilt themes are present.5 METHODS Moreover, OCD patients experience higher state- guilt, trait-guilt, and moral standards vs controls. In addi- We conducted a literature search using psychological, tion, trait-guilt predicts obsessive complaints in non-OCD medical, and theological databases (FIGURE). Identified control samples. Guilt also appears to play a role in OC citations included 135 from PsychInfo (1930 to present), symptoms that is independent of and additive to inflated 66 from Journal Storage (JSTOR), 24 from PubMed (1973 to responsibility. For example, guilt-related life events worsen present), 9 from Academic One File, 5 from PsychNet, and 1 obsessiveness, and increased guilt is associated with OCD from the American Theological Library Association (ATLA) severity.6,9 Fortunately, a practical, validated measure was religious database. Three relevant theological dissertations also identified that differentiates state- vs trait-guilt for use were also obtained through JSTOR. Threshold criteria for in nonclinical and OCD samples.40 manuscript inclusion in this review were defined by the With regard to an additional search conducted to iden- presence of an empiric, prospective qualitative, or quan- tify guilt in other psychiatric disorders, MDD and PTSD titative approach, of psychometric measure development, accounted for the majority of guilt-related symptomatology. or of a critical review of the topic. One case study describ- The few other results involved guilt in prolonged bereave- ing the negative impact of guilt on OCD-affected individu- ment, and grief over the loss of a loved one, survivor guilt (liv- als was excluded from the review due to its non-empiric, ing on after the loss of a loved one), and having more material anecdotal nature.36 All identified studies were summarized possessions or physical gifts than loved ones. These contrib-

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TABLE Studies included in literature review of guilt and OCD Sample Author size, n Sample type Measures Findings summary Nonclinical samples Gangemi et al, 120 Undergraduates, PGI/S&T Threat perception associated with: 20071 postgraduates 1) trait-guilt 2) state-guilt in high trait Mancini et al, n/a Review n/a Guilt increases OC symptoms independent 200361 of inflated responsibility

Mancini et al, 104 Undergraduates PGI/S&T; ST-NJREQ; PI; PI-R Trait-guilt: 20082 1) increases NJREs 2) associated with NJRE and OC-symptoms Mancini et al, 47 Nonclinical Object location, memory task OC-like behavior in normal people 20044 increased by fear of state-guilt Niler et al, 198937 76 Undergraduates STAI; BDI; PGI; ITIS Perceived guilt best predictor of intrusive thoughts and impulses Otterbacher et al, 233 Undergraduates PGI State- and trait-guilt measure: 197340 Strong construct validity Nissenson, 20063 299 Undergraduates PGI/S&T; VOCI; OBQ; DASS Perceived responsibility is: 1) inflated by state- and trait-guilt 2) unchanged by psychoeducation Shecterle, 199934 281 Lay/religious TOSCA; PFQ2; ISS; BDI; IELCS; Guilt/shame proneness is associated with religion leaders STAI; STAEI; RIS; PCBS; AUIEROS Takahashi et al, 19 Nonclinical fMRI; verbal suggestions Guilt/embarrassment associated with: 200438 1) increased medial prefrontal cortex 2) increased L post supratemporal sulcus 3) increased visual cortical activity Shin et al, 200039 8 Nonclinical males PET; scripted imagery Guilt increases regional CBF in 3 paralimbic regions

Clinical samples Savoie, 19965 9 OC patients Interview 15 guilt/OCD themes are described Tallis, 19947 2 OC patients n/a Life events triggered: Obsessive responsibility, guilt, TAF Shafran et al, 60 OC patients PGI/S&T; BDI; BAI; MOCI OCD has higher state- and trait-guilt vs controls. 19966 Healthy controls Trait-guilt predict obsessionality Steketee et al, 57 OC patients PSQ; MOCI; CAC; BDI; STAI; FNE OCD severity correlates with most guilt measures 19919 Anxiety patients

AUIEROS: Age Universal Intrinsic/Extrinsic Religious Orientation Scale; BAI: Beck Anxiety Inventory; BDI: Beck Depression Inventory; CAC: Compulsive Activity Checklist; CBF: cerebral blood flow; DASS: Depression Anxiety Stress Scale; fMRI: functional magnetic resonance imaging; FNE: Fear of Negative Evaluation; IELCS: Internal-External Locus of Control Scale; ISS: Internalized Shame Scale; ITIS: Intrusive Thoughts and Impulses Survey; MOCI: Maudsley Obsessive-Compulsive Inventory; NJRE: not-just- right experiences; OBQ: Obsessional Belief Scale; OC: obsessive compulsive; OCD: obsessive-compulsive disorder; PCBS: Post-Critical Belief Scale: PET: positron emission tomography; PFQ2: Personal Feelings Questionnaire 2; PGI: Perceived Guilt Inventory; PGI/S&T: Perceived Guilt Inventory/State and Trait; PI: Padua Inventory; PI-R: Padua Inventory-Revised; PSQ: Perceived Stress Questionnaire; RIS: Religious Involvement Scale; STAEI: State-Trait Anger Expression Inventory; STAI: State-Trait Anxiety Inventory; ST-NJREQ: State/Trait-Not Just Right Experiences Questionnaire; TAF: Though-Action-Fusion; TOSCA: Test of Self-Conscious Affect; VOCI: Vancouver Obsessive Compulsive Inventory. uted to other types of depression, morbid preoccupation with shame, survivor guilt, separation guilt, omnipotent responsi- guilt, suicidal ideation, or psychomotor retardation.41 Guilt bility guilt, self-hate guilt, trait guilt, and state guilt compared was associated with fears of scrutiny and rejection by others in with a sample of nondrug-addicted controls.45,46 body dysmorphic disorder42 and social anxiety disorder.43 In those with eating disorders, ineffective alleviation of guilt feel- Nonclinical samples ings related to eating and exercise was correlated with depres- Gangemi et al1 found that state-guilt and subjective emo- sion and greater eating disturbances.44 In polysubstance tional responses drew invalid conclusions about threat in abuse, those in recovery showed higher levels of depression, normal controls. While the concept of inflated responsi-

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bility has been identified as a strong motivator for ritualis- research subjects. In 1 study, functional MRI showed tic responses to obsessions, anticipation, and fear of guilt activation in medial prefrontal cortices, left posterior were found to be independently important in assessing and superior temporal sulci, and the visual cortex areas the severity and likelihood of hypothetical danger in a of the brain, when subjects read guilty or embarrassing nonclinical sample with high-trait guilt. However, this non-neutral scenarios.38 In a similar study, research sub- was not the case with anxious or low-trait guilt subjects.4 jects were instructed to recall the situation in which they NJREs are described as uncomfortable sensations experienced the most guilt, while undergoing a positron that signal a perceived mismatch between the state of the emission tomography scan to observe cerebral blood world or of one’s own performance and the individual’s flow. Under the same conditions, control subjects were accepted standards.2 Individuals with OCD frequently instructed to recall an emotionally neutral experience. In report uncomfortable sensations of things being not the guilt-induction study group, increased blood flow in quite right and subsequently feel driven to perform an the anterior paralimbic regions of the brain occurred.39 action until this uncomfortable sensation is reduced.47,48 OCD symptom severity has been moderately cor- In a study of nonclinical samples, it was reported that related with most guilt measures in OCD patient popula- state-guilt induction produced higher reactivity to NJREs tions.9 In addition, feelings of guilt may precede, motivate, in those with high-trait but not with low-trait guilt.2 or be a consequence of OCD symptoms.5 Fifteen common The Perceived Guilt Index (PGI)40 has been utilized themes emerged in a study from interviews with OCD in several studies to date. This is a brief and validated outpatients. Individuals identified guilt as an interfering measure that differentiates state- and trait-guilt for use component of their OCD, and discussed guilt in the con- in nonclinical and OCD samples.1-3,6,37 This measure was text of several themes5: 1) forbidden thoughts, feelings, developed to add data on both the affective qualities of and behaviors; 2) hyperresponsibility/omnipotence; 3) guilt and on the impact of an experienced situation on conflicts between internal standards and external behav- perceived guilt. It has 2 subscales, assessing guilt as a iors; 4) rituals alleviating existing guilt; 5) fear-of-guilt as a generalized self-concept (G-Trait) and guilt as a transient motivating factor in rituals; 6) inadequate justification; 7) affective state (G-State). The PGI has also been found to being a bad mother/wife; 8) being a bad daughter/son; 9) be sensitive to change. being a bad friend; 10) resultant interpersonal isolation/ alienation; 11) perceived failing of the self; 12) waste; 13) Dissertations difficulty coping with guilt; 14) resultant clinical improve- The Intrusive Thoughts and Impulses Survey (ITIS) is a guilt- ment and the loss of conscientiousness; and 15) emergent related measure that was devised in a dissertation.3 Using a reparation. Moreover, OCD subjects were found to expe- sample of 76 college students, guilt was found to be the most rience more state- and trait-guilt, and higher moral stan- robust predictor of the content of intrusive thoughts and dards than controls. In both subject groups, trait-guilt pre- impulses. State- and trait-guilt was reported to increase per- dicted more obsessionality, independent of the presence ceived responsibility and listening to supportive statements of anxiety or depression. did not result in reduced perceived responsibility, guilt, or stress. Another dissertation34 studied guilt across 4 religious traditions (Conservative Judaism, Roman Catholic, Evan- DISCUSSION gelical Lutheran, and Black Baptist). Guilt was found to be significantly related to denomination in lay and religious Guilt is a prominent and enduring symptom of human leaders. The data did not support the thesis that Jews experi- suffering that has been described over the centuries in ence a higher proneness to guilt than Christians. However, lay, biologic, psychological, and theological literature. Lutherans were substantially more guilt-prone that Roman The ensuing search to escape guilt often is brought to Catholics in those study samples. psychological or religious venues. Typically, the ensuing interactions with mental health professionals or Clinical samples clergy aim to help people accept their human “flaws” and Neuroimaging studies have demonstrated that guilt “imperfections,” while validating personal strengths and induction in healthy controls increased brain activity in self-efficacy as tools for improvement. areas proximal to regions of interest identified in OCD While adaptive guilt serves to inform individuals when

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they have truly wronged another or violated a personal will die” mandates that the person be an observer, not a standard for which rectification is appropriate,49 PG drives participant, of the obsession. However, the combination of an intense need for certainty over a “normal” incident, for state-guilt (related to having the thought) and uncertainty which rectification is neither necessary nor appropriate. as to whether this thought will either affect reality (magical Within the religious setting, religious rituals have emerged thinking) or trigger state-anxiety (experienced as a surge of to address and absolve guilt, while the therapeutic approach physiological anxiety symptoms such as rapid heart rate, aims to identify dysfunctional guilt, religious or otherwise, shallow breathing, or a feeling of dread) often create a bind and to provide the means to normalize it. Both religious and when clinical and “moral” issues become conflated. clinical spheres have their benefits and limitations. With regard to trait-guilt and trait-anxiety, the person PG frequently produces compulsive reassurance seek- in this example may have previously learned that thoughts ing and, ironically, has an unintended detrimental effect are equivalent to deeds (ie, having the thought increases as the “target” person becomes exasperated. In contrast to the likelihood of death, and/or that the obsession is an adaptive guilt, PG is motivated by the desire to ensure that indication of the wish for this to happen). After observing the “wrong” is made “right,” often at the expense of main- the color red in the environment, an OCD-affected indi- taining social norms and mutuality of social relationships. vidual with trait-guilt may identify excessive ritualizing as PG is a prominent feature of the putative OCD subtype the most appropriate expression of penitence. labeled “scrupulosity.” Individuals with prominent scrupu- In clinical treatment settings, exposure work for this losity often transform normative conventional religious rit- individual may involve purposely looking at the color red uals into compulsive rituals. Common scrupulosity rituals or wishing deliberately for the mother to die, while resist- related to PG include prayer, confession, purification/wash- ing all compulsive urges to ritualize. Although the efficacy ing, mental neutralization, and pact making (with God). of this 2-pronged approach for OCD treatment is well doc- In contrast, conventional religious rituals are normally umented,50-53 unaddressed PG may call into question the practiced to maintain traditions, participate in community, “morality” of this exposure and override the individual’s and to experience momentary peace in the face of prob- ability to comply fully with exposure and response preven- lems and stress. As an example, religious prayer is meant to tion (ERP). In many cases such as the above, treatment enhance a healthy practice of faith by creating moments of often plateaus before the therapeutic range of habituation calm reflection and meaning. The quality and duration of a has been achieved. Once PG is identified, strategies to tar- normal prayer has a “natural” beginning and end. get Thought-Action-Fusion (TAF) could be implemented However, similar to the detrimental effect compulsive to dispel cognitive distortions that interfere with recovery. reassurance has on interpersonal interactions, scrupulous Adjunctive religious counsel also could be utilized to pro- rituals serve the opposite function of their intended pur- vide the religious “authority” to conduct the ERP task. This pose. Scrupulous rituals are driven not only by an obses- also could validate the necessity to adopt a more mature sive need for certainty, to achieve a state of perfection, and relationship to one’s limitations, to respect for self, and to to feel “right,” but also to allay guilt caused by an obsession move beyond the literal practice of faith. that violated the literal “letter” of the religious law (ie, a blas- Exploring the role that state-guilt and trait-guilt play phemous thought). As a result, the “spirit” of the religious in OCD may reveal that trait-guilt becomes exacerbated by law—that one is forgiven for (unintended) transgressions— the onset of OCD, and/or that the OCD episode provokes becomes lost on the sufferer who does not experience the excessive state-guilt (due to the premorbid style of cop- intended restorative benefit the ritual was created to pro- ing with negative and uncertain situations, especially with vide. Instead, untoward compulsive rituals are performed interpersonal interactions). Although the PGI40 is a validated as “contrition” to prove to God that the violation (obses- measure of state- and trait-guilt, the creation of a more OCD- sion) of the religious “letter of the law” was unintended, and specific measure would be valuable in evaluating the effects that absolution and forgiveness is therefore assured. These of PG on OCD treatment and recovery. Research designed rituals rarely reach completion. to identify the frequency, severity, incidence, and relapse of It is likely that state-guilt and state-anxiety exacerbate PG may help to reveal the extent to which guilt impacts treat- the anxiety response to an obsession when thought and ment, as well as improving understanding of the nature of action become fused. For example, cognitive-behavioral patients’ ambivalence toward ERP compliance. therapy (CBT) for the obsession “If I see red, my mother With regard to the psychological, psychiatric, and theo-

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logical literature included in this review, 3 central themes higher frequency of religious involvement correlated with emerged in describing the interconnectedness between guilt internal LOC in Protestants and Jews, whereas the opposite and OCD. These are as follows: 1) guilt may lead to OC-like was true in the Catholic sample. Analyzing these and other symptoms in healthy individuals; 2) state-guilt in healthy LOC findings may further identify contributory factors to samples activates brain regions proximal to those implicated the complex cognitive and affective systems impacting how in OCD; and 3) higher levels of state-guilt and trait-guilt are OCD is experienced. reported in OCD subjects vs healthy controls. As such, current literature suggests that guilt is not restricted to the scru- Limitations pulosity subtype, and that its impact should be considered in The lack of updated guilt measures, especially related to the assessment and management of all OCD patients. state- and trait-guilt, and the absence of OCD-specific It is hypothesized that post-CBT relapses may occur guilt measures limited the ability of this review to more when high state-guilt—especially high trait-guilt—have not clearly operationalize factors involved in this construct. been adequately addressed under otherwise excellent ERP The creation of a reliable and valid research measure that treatment conditions. Some authors have attributed great delineates the effects of PG in OCD would be a valuable importance to “inflated responsibility” as a discrete dys- contribution to better understand and treat a meaningful, functional cognitive domain of OCD.54-58 However, more but often ignored, aspect of refractory symptoms within the recent investigations of “treatment-resistant” OCD have standard OCD treatment framework. suggested that guilt may be an equally salient factor.1,2,4 Inaccessibility of pertinent archived theological lit- Thus, the relationship between PG and OCD appears erature (that would likely provide insights into historic complex. Given the cross-sectional nature of the studies formulations and ministrations of how obsessive guilt is examined, it is unclear as to whether increased guilt in addressed within the laity) is another limitation of this OCD is a product of the disorder (state), whether trait-guilt review. Likewise, the impact of historic psychological theo- is a vulnerability factor for the onset of OCD, or whether ries of guilt (ie, the psychoanalytic perspective of guilt/OCD brain pathology in OCD leads to increased expression of serving as a defense mechanism against conflict between guilt (which appears to activate similar brain regions). the superego and the id; and of guilt serving to defend the Clinicians are obligated to provide the most appropri- individual from acting on impulsive/aggressive urges) as ate means of treatment that specifically target the present- contributors to the current OCD treatment culture was ing problem. With improved PG-related assessment and not discussed here. This was considered to be beyond the data collection, clinical interventions could be tailored to scope of the present review. help sufferers reattribute their PG as an OCD symptom, rather than as an indicator of their insufficient morality. Development of precise strategies that differentially CONCLUSIONS target OCD-related state- and trait-guilt may help to opti- mize therapeutic effects of ERP. Specifically, cognitive Based on collective clinical experience, and supported by therapy approaches targeting TAF, management of nega- the results of this review, further applied research of PG in tive emotions, issues around homeostasis, and unaccom- OCD will better inform the field. Attention to this under- plished age-appropriate developmental issues stemming recognized and under-treated factor across OCD subtypes from PG/OCD are likely to be promising areas of interest may subsequently improve treatment outcome. Emer- for enhancing treatment outcome. gent data may help to determine whether CBT strategies Future research may also include examination of the focused on PG have the potential to impact better treat- role that locus of control (LOC) plays in religion and OCD. ment outcome and sustained recovery. The prevalence of A useful tool for this may be Rotter’s Internal-External (I-E) PG in OCD could be determined through the development scale59 which measures the extent to which people believe of valid assessment measures that identify the incidence of they have control and determination over their lives (inter- state- and trait-guilt for individual OCD clinical cases. Once nal control) vs the degree to which they feel their destinies this is established, differentially appropriate and effective are beyond their personal control and are determined by CBT strategies may be developed to address the indepen- fate, chance, or powerful others (external control). Counter dent variables of state-guilt, trait-guilt, and any possible to clinical intuition, a study60 using the I-E scale found that synergistic effects they may cause in refractory OCD cases.

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OCD symptoms are clinically heterogeneous, but Whether guilt is a naturally selected evolutionary trait clinical experience in treating PG demonstrates that the (reciprocal altruism)20 that keeps individuals safe from individual’s response to his/her particular symptoms one another, whether it is a function of neurobiology, or is more important than the symptoms themselves. We whether it is conditionally learned from authority figures hypothesize that PG is not limited to the scrupulosity and/or one’s environment, it is clear that OCD further subtype, but occurs across almost all OCD subtypes. exploits those already vulnerable to guilt. ■ Development of evidence-based treatment strategies may result in a more robust treatment outcome for DISCLOSURES: The authors report no financial relation- those who have been previously considered “treatment ship with any company whose products are mentioned in refractory.” this article or with manufacturers of competing products.

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70 February 2011 | Vol. 23 No. 1 | Annals of Clinical Psychiatry