Pathological guilt: A persistent yet overlooked treatment factor in obsessive-compulsive disorder
OCD Institute, McLean Hospital, Belmont, MA, USAEvelyn S Stewart, MD
OCD Institute, McLean Hospital, Belmont, MA, USA, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
BACKGROUND: Guilt appears to be a factor that may increase the severity of obsessive-compulsive disorder (OCD) and negatively impact treatment outcomes. However, researchers and clinicians have paid little attention to addressing guilt in OCD treatment. Because guilt is an important perpetuating and mediating factor for OCD symptoms and the development of guilt-specific strategies may yield improved treatment outcomes, we hypothesized that a review of the relevant literature may provide important 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. Development 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 lead to improved treatment outcomes and fewer relapses for this debilitating and frequently chronic illness.
KEYWORDS: OCD, guilt, state, trait, moral, responsibility
ANNALS OF CLINICAL PSYCHIATRY 2011;23(1):63-70
It has been suggested that guilt may negatively impact the severity and treatment outcome of obsessive-compulsive disorder (OCD). Interest in the role of guilt in OCD has recently resurfaced.1-4 Although guilt has been intermittently cited as an important mediator of outcome by OCD investigators,5-9 no clinical treatment protocols have been devised to effectively address this factor. It is unclear whether unaddressed guilt in OCD leads to relapse following an otherwise effective course of treatment, and/ or if guilt is a responsible component in treatment refractoriness of some OCD cases. We hypothesized that guilt is a significant perpetuating factor for OCD symptoms and that development of effective guilt-specific strategies could yield improved outcomes. To examine contributions on this topic across psychological and theological disciplines, we reviewed the body of relevant literature on guilt in OCD.
The heterogeneous symptoms of OCD are well described by the Young-Brown Obsessive Compulsive Scale (Y-BOCS) Symptom Checklist.10 While PG is frequently conceptualized as a major component of OCD -related scrupulosity (obsessions that involve religious and/or moral content),11-19 its impact extends beyond this context. From a clinical perspective, guilt may mediate most other obsessions, including aggressive, contamination, sexual, religious, symmetry/exactness, and other obsessions. It may also motivate nearly all compulsion subtypes, including cleaning, checking, repeating, counting, ordering, and miscellaneous compulsions. Although descriptions of guilt in OCD have been provided with respect to scrupulosity patients, it has been largely ignored in discussion of other OCD subtypes. Rather, a sense of inflated responsibility has been identified as the primary concern regarding the “moral” aspect of obsessions.4
For many patients with OCD, the concern is not that they will be responsible for the consequences of their obsessions; rather, they fear that the obsessive thoughts indicate an unintended wish for them to happen. An OCD sufferer might be unaware that he or she is angry with a loved one and may begin to have intrusive morbid thoughts about that person. For example, an adult daughter may experience underlying frustration at her mother who continues to be overprotective. The daughter suddenly has intrusive thoughts about stabbing her mother while they prepare dinner. With regard to not-just-right experiences (NJREs), frequent and intense guilt feelings and the fear of guilt itself, have been detected as an inherent vulnerability in those with OCD.2 Further, it has been suggested that acting on OCD symptoms often has an intention of avoiding guilt for fear of acting irresponsibly.1 Bringing this affective component to awareness during treatment may lead to improved outcomes and fewer relapses for this debilitating and frequently chronic illness.
Classification of guilt
Guilt is a concept that has been examined across multiple disciplines, including biologic, psychological, and theological. Evolutionary biology describes guilt as a component of “reciprocal altruism.” By this definition, guilt is advantageous as it regulates opportunistic behaviors such as those that maintain social relationships.20 According to this definition, guilt is adaptive and protects humans from one another.
Guilt also is a factor in other psychiatric disorders. Major depressive disorder (MDD) includes excessive or inappropriate guilt as a diagnostic affective component, along with feelings of worthlessness.21 Interestingly, Alexander et al22 found guilt, but not shame, to be associated with levels of depression.
Guilt also is found in both simple and complex posttraumatic stress disorder (PTSD).23 Hathaway et al24 reported that emotions of guilt, anger, shame, sadness, and numbing occurred more frequently than fear in PTSD. Guilt-based PTSD was recognized as a subtype requiring specialized treatment strategies25 and trauma-related guilt was associated with increased PTSD symptomatology through the use of avoidant coping strategies.26
In the current review paper, we utilize the inclusive construct of guilt as examined across disciplines and over time to explore how it pertains to OCD. Guilt has been defined by psychologists, psychiatrists, and clinicians as a disagreeable emotional condition associated with transgression of personal rules, morals, or mores. By this definition, guilt may resolve with reparation, restitution or confession, and forgiveness.27 Additional clinical definitions of guilt have included the following: guilt as an expression of self-reproach and remorse for one’s behavior (as if one violated a moral principle)28; as a drive that motivates compulsive responses29; as the resultant dysphoric feeling upon the realization of violating a personally relevant moral or social standard30; and as chronic self-blame and obsessive rumination over some objectionable or harmful behavior.31 In historical psychoanalytic literature Vergote32 stated, “Guilt and desire, because of their fundamental nature, are the two themes at the heart of religion and psychoanalysis.”
In theological and religious literature, the central tenet of guilt is associated with “condemnation” related to a breach of divine precepts or rules, regulations, and laws of a particular organized religion or church, which is similar to psychologically defined guilt.33 In biblical text, the terms guilt and sin are used interchangeably.34 Text from the Old Testament identifies guilt as “spiritual and moral failure, toward one’s fellow man or toward God”; as “deliberate revolting, rebelling, and transgressing against God”; and as “the being or acting wrongly or pervertedly.”35 Text from the New Testament indicates a shift in attitude about sin and guilt by declaring real and certain victory over sin.
We conducted a literature search using psychological, medical, and theological databases (FIGURE). Identified citations included 135 from PsychInfo (1930 to present), 66 from Journal Storage (JSTOR), 24 from PubMed (1973 to present), 9 from Academic One File, 5 from PsychNet, and 1 from the American Theological Library Association (ATLA) religious database. Three relevant theological dissertations were also obtained through JSTOR. Threshold criteria for manuscript inclusion in this review were defined by the presence of an empiric, prospective qualitative, or quantitative approach, of psychometric measure development, or of a critical review of the topic. One case study describing the negative impact of guilt on OCD-affected individuals was excluded from the review due to its non-empiric, anecdotal nature.36 All identified studies were summarized to evaluate differential perspectives and recommendations regarding this construct across clinical and theological pastoral settings. References from each manuscript were used to identify additional manuscripts in an iterative manner.
FIGURE Selection of publications for review
OCD: obsessive-compulsive disorder.
Relevant articles were selected from the initial database search results according to defined threshold criteria. Manuscripts meeting the criteria included 10 from PubMed, 7 from Academic OneFile, 5 from PsychNet, and 1 from both JSTOR and ATLA. Several of these were identified by ≥1 database, such that the total number of identified papers for review focusing specifically on guilt and OCD was 14. Among these, 11 were clinical research studies (including 2 dissertations, 1 case study, and 1 psychometric measure development), 2 were neuroimaging research studies, and 1 was a literature review. Authors, samples sizes, sample types, measures, and results for each of these studies are summarized in the TABLE.
The outcomes of this review on the identification of PG as a clinically important factor in OCD are summarized in the TABLE. Three central themes emerged on the role of guilt in OCD, as follows: 1) in nonclinical samples guilt leads to obsessive-compulsive (OC)-like symptoms, including increased threat perception, NJREs, overresponsibility, and intrusive thoughts/impulses1,2,37; 2) in nonclinical 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
Moreover, OCD patients experience higher state-guilt, trait-guilt, and moral standards vs controls. In addition, trait-guilt predicts obsessive complaints in non-OCD control samples. Guilt also appears to play a role in OC symptoms that is independent of and additive to inflated responsibility. For example, guilt-related life events worsen obsessiveness, and increased guilt is associated with OCD severity.6,9 Fortunately, a practical, validated measure was also identified that differentiates state- vs trait-guilt for use in nonclinical and OCD samples.40
With regard to an additional search conducted to identify guilt in other psychiatric disorders, MDD and PTSD accounted for the majority of guilt-related symptomatology. The few other results involved guilt in prolonged bereavement, and grief over the loss of a loved one, survivor guilt (living on after the loss of a loved one), and having more material possessions or physical gifts than loved ones. These contributed to other types of depression, morbid preoccupation with guilt, suicidal ideation, or psychomotor retardation.41 Guilt was associated with fears of scrutiny and rejection by others in body dysmorphic disorder42 and social anxiety disorder.43 In those with eating disorders, ineffective alleviation of guilt feelings related to eating and exercise was correlated with depression and greater eating disturbances.44 In polysubstance abuse, those in recovery showed higher levels of depression, shame, survivor guilt, separation guilt, omnipotent responsibility guilt, self-hate guilt, trait guilt, and state guilt compared with a sample of nondrug-addicted controls.45,46
Studies included in literature review of guilt and OCD
||Sample size, n
|Gangemi et al, 20071
||Threat perception associated with:
2) state-guilt in high trait
|Mancini et al, 200361
||Guilt increases OC symptoms independent of inflated responsibility
|Mancini et al, 20082
||PGI/S&T; ST-NJREQ; PI; PI-R
1) increases NJREs
2) associated with NJRE and OC-symptoms
|Mancini et al, 20044
||Object location, memory task
||OC-like behavior in normal people increased by fear of state-guilt
|Niler et al, 198937
||STAI; BDI; PGI; ITIS
||Perceived guilt best predictor of intrusive thoughts and impulses
|Otterbacher et al, 197340
||State- and trait-guilt measure: Strong construct validity
||PGI/S&T; VOCI; OBQ; DASS
||Perceived responsibility is:
1) inflated by state- and trait-guilt
2) unchanged by psychoeducation
||TOSCA; PFQ2; ISS; BDI; IELCS; STAI; STAEI; RIS; PCBS; AUIEROS
||Guilt/shame proneness is associated with religion
|Takahashi et al, 200438
||fMRI; verbal suggestions
||Guilt/embarrassment associated with:
1) increased medial prefrontal cortex
2) increased L post supratemporal sulcus
3) increased visual cortical activity
|Shin et al, 200039
||PET; scripted imagery
||Guilt increases regional CBF in 3 paralimbic regions
||15 guilt/OCD themes are described
||Life events triggered: Obsessive responsibility, guilt, TAF
|Shafran et al, 19966
||OC patients Healthy controls
||PGI/S&T; BDI; BAI; MOCI
||OCD has higher state- and trait-guilt vs controls. Trait-guilt predict obsessionality
|Steketee et al, 19919
||OC patients Anxiety patients
||PSQ; MOCI; CAC; BDI; STAI; FNE
||OCD severity correlates with most guilt measures
Gangemi et al1 found that state-guilt and subjective emotional responses drew invalid conclusions about threat in normal controls. While the concept of inflated responsibility has been identified as a strong motivator for ritualistic responses to obsessions, anticipation, and fear of guilt were found to be independently important in assessing the severity and likelihood of hypothetical danger in a nonclinical sample with high-trait guilt. However, this was not the case with anxious or low-trait guilt subjects.4
NJREs are described as uncomfortable sensations that signal a perceived mismatch between the state of the world or of one’s own performance and the individual’s accepted standards.2 Individuals with OCD frequently report uncomfortable sensations of things being not quite right and subsequently feel driven to perform an action until this uncomfortable sensation is reduced.47,48 In a study of nonclinical samples, it was reported that state-guilt induction produced higher reactivity to NJREs in those with high-trait but not with low-trait guilt.2
The Perceived Guilt Index (PGI)40 has been utilized in several studies to date. This is a brief and validated measure that differentiates state- and trait-guilt for use in nonclinical and OCD samples.1-3,6,37 This measure was developed to add data on both the affective qualities of guilt and on the impact of an experienced situation on perceived guilt. It has 2 subscales, assessing guilt as a generalized self-concept (G-Trait) and guilt as a transient affective state (G-State). The PGI has also been found to be sensitive to change.
The Intrusive Thoughts and Impulses Survey (ITIS) is a guilt-related measure that was devised in a dissertation.3 Using a sample of 76 college students, guilt was found to be the most robust predictor of the content of intrusive thoughts and impulses. State- and trait-guilt was reported to increase perceived responsibility and listening to supportive statements did not result in reduced perceived responsibility, guilt, or stress. Another dissertation34 studied guilt across 4 religious traditions (Conservative Judaism, Roman Catholic, Evangelical Lutheran, and Black Baptist). Guilt was found to be significantly related to denomination in lay and religious leaders. The data did not support the thesis that Jews experience a higher proneness to guilt than Christians. However, Lutherans were substantially more guilt-prone that Roman Catholics in those study samples.
Neuroimaging studies have demonstrated that guilt induction in healthy controls increased brain activity in areas proximal to regions of interest identified in OCD research subjects. In 1 study, functional MRI showed activation in medial prefrontal cortices, left posterior and superior temporal sulci, and the visual cortex areas of the brain, when subjects read guilty or embarrassing non-neutral scenarios.38 In a similar study, research subjects were instructed to recall the situation in which they experienced the most guilt, while undergoing a positron emission tomography scan to observe cerebral blood flow. Under the same conditions, control subjects were instructed to recall an emotionally neutral experience. In the guilt-induction study group, increased blood flow in the anterior paralimbic regions of the brain occurred.39
OCD symptom severity has been moderately correlated with most guilt measures in OCD patient populations.9 In addition, feelings of guilt may precede, motivate, or be a consequence of OCD symptoms.5 Fifteen common themes emerged in a study from interviews with OCD outpatients. Individuals identified guilt as an interfering component of their OCD, and discussed guilt in the context of several themes5: 1) forbidden thoughts, feelings, and behaviors; 2) hyperresponsibility/omnipotence; 3) conflicts between internal standards and external behaviors; 4) rituals alleviating existing guilt; 5) fear-of-guilt as a motivating factor in rituals; 6) inadequate justification; 7) being a bad mother/wife; 8) being a bad daughter/son; 9) being a bad friend; 10) resultant interpersonal isolation/ alienation; 11) perceived failing of the self; 12) waste; 13) difficulty coping with guilt; 14) resultant clinical improvement and the loss of conscientiousness; and 15) emergent reparation. Moreover, OCD subjects were found to experience more state- and trait-guilt, and higher moral standards than controls. In both subject groups, trait-guilt predicted more obsessionality, independent of the presence of anxiety or depression.
Guilt is a prominent and enduring symptom of human suffering that has been described over the centuries in lay, biologic, psychological, and theological literature. The ensuing search to escape guilt often is brought to psychological or religious venues. Typically, the ensuing interactions with mental health professionals or clergy aim to help people accept their human “flaws” and “imperfections,” while validating personal strengths and self-efficacy as tools for improvement.
While adaptive guilt serves to inform individuals when they have truly wronged another or violated a personal standard for which rectification is appropriate,49 PG drives an intense need for certainty over a “normal” incident, for which rectification is neither necessary nor appropriate. Within the religious setting, religious rituals have emerged to address and absolve guilt, while the therapeutic approach aims to identify dysfunctional guilt, religious or otherwise, and to provide the means to normalize it. Both religious and clinical spheres have their benefits and limitations.
PG frequently produces compulsive reassurance seeking and, ironically, has an unintended detrimental effect as the “target” person becomes exasperated. In contrast to adaptive guilt, PG is motivated by the desire to ensure that the “wrong” is made “right,” often at the expense of maintaining social norms and mutuality of social relationships.
PG is a prominent feature of the putative OCD subtype labeled “scrupulosity.” Individuals with prominent scrupulosity often transform normative conventional religious rituals into compulsive rituals. Common scrupulosity rituals related to PG include prayer, confession, purification/washing, mental neutralization, and pact making (with God).
In contrast, conventional religious rituals are normally practiced to maintain traditions, participate in community, and to experience momentary peace in the face of problems and stress. As an example, religious prayer is meant to enhance a healthy practice of faith by creating moments of calm reflection and meaning. The quality and duration of a normal prayer has a “natural” beginning and end.
However, similar to the detrimental effect compulsive reassurance has on interpersonal interactions, scrupulous rituals serve the opposite function of their intended purpose. Scrupulous rituals are driven not only by an obsessive need for certainty, to achieve a state of perfection, and to feel “right,” but also to allay guilt caused by an obsession that violated the literal “letter” of the religious law (ie, a blasphemous thought). As a result, the “spirit” of the religious law—that one is forgiven for (unintended) transgressions— becomes lost on the sufferer who does not experience the intended restorative benefit the ritual was created to provide. Instead, untoward compulsive rituals are performed as “contrition” to prove to God that the violation (obsession) of the religious “letter of the law” was unintended, and that absolution and forgiveness is therefore assured. These rituals rarely reach completion.
It is likely that state-guilt and state-anxiety exacerbate the anxiety response to an obsession when thought and action become fused. For example, cognitive-behavioral therapy (CBT) for the obsession “If I see red, my mother will die” mandates that the person be an observer, not a participant, of the obsession. However, the combination of state-guilt (related to having the thought) and uncertainty as to whether this thought will either affect reality (magical thinking) or trigger state-anxiety (experienced as a surge of physiological anxiety symptoms such as rapid heart rate, shallow breathing, or a feeling of dread) often create a bind when clinical and “moral” issues become conflated.
With regard to trait-guilt and trait-anxiety, the person in this example may have previously learned that thoughts are equivalent to deeds (ie, having the thought increases the likelihood of death, and/or that the obsession is an indication of the wish for this to happen). After observing the color red in the environment, an OCD-affected individual with trait-guilt may identify excessive ritualizing as the most appropriate expression of penitence.
In clinical treatment settings, exposure work for this individual may involve purposely looking at the color red or wishing deliberately for the mother to die, while resisting all compulsive urges to ritualize. Although the efficacy of this 2-pronged approach for OCD treatment is well documented,50-53 unaddressed PG may call into question the “morality” of this exposure and override the individual’s ability to comply fully with exposure and response prevention (ERP). In many cases such as the above, treatment often plateaus before the therapeutic range of habituation has been achieved. Once PG is identified, strategies to target Thought-Action-Fusion (TAF) could be implemented to dispel cognitive distortions that interfere with recovery. Adjunctive religious counsel also could be utilized to provide the religious “authority” to conduct the ERP task. This also could validate the necessity to adopt a more mature relationship to one’s limitations, to respect for self, and to move beyond the literal practice of faith.
Exploring the role that state-guilt and trait-guilt play in OCD may reveal that trait-guilt becomes exacerbated by the onset of OCD, and/or that the OCD episode provokes excessive state-guilt (due to the premorbid style of coping with negative and uncertain situations, especially with interpersonal interactions). Although the PGI40 is a validated measure of state- and trait-guilt, the creation of a more OCD-specific measure would be valuable in evaluating the effects of PG on OCD treatment and recovery. Research designed to identify the frequency, severity, incidence, and relapse of PG may help to reveal the extent to which guilt impacts treatment, as well as improving understanding of the nature of patients’ ambivalence toward ERP compliance.
With regard to the psychological, psychiatric, and theological literature included in this review, 3 central themes emerged in describing the interconnectedness between guilt and OCD. These are as follows: 1) guilt may lead to OC-like symptoms in healthy individuals; 2) state-guilt in healthy samples activates brain regions proximal to those implicated in OCD; and 3) higher levels of state-guilt and trait-guilt are reported in OCD subjects vs healthy controls. As such, current literature suggests that guilt is not restricted to the scrupulosity subtype, and that its impact should be considered in the assessment and management of all OCD patients.
It is hypothesized that post-CBT relapses may occur when high state-guilt—especially high trait-guilt—have not been adequately addressed under otherwise excellent ERP treatment conditions. Some authors have attributed great importance to “inflated responsibility” as a discrete dysfunctional cognitive domain of OCD.54-58 However, more recent investigations of “treatment-resistant” OCD have suggested that guilt may be an equally salient factor.1,2,4
Thus, the relationship between PG and OCD appears complex. Given the cross-sectional nature of the studies examined, it is unclear as to whether increased guilt in OCD is a product of the disorder (state), whether trait-guilt is a vulnerability factor for the onset of OCD, or whether brain pathology in OCD leads to increased expression of guilt (which appears to activate similar brain regions).
Clinicians are obligated to provide the most appropriate means of treatment that specifically target the presenting problem. With improved PG-related assessment and data collection, clinical interventions could be tailored to help sufferers reattribute their PG as an OCD symptom, rather than as an indicator of their insufficient morality.
Development of precise strategies that differentially target OCD-related state- and trait-guilt may help to optimize therapeutic effects of ERP. Specifically, cognitive therapy approaches targeting TAF, management of negative emotions, issues around homeostasis, and unaccomplished age-appropriate developmental issues stemming from PG/OCD are likely to be promising areas of interest for enhancing treatment outcome.
Future research may also include examination of the role that locus of control (LOC) plays in religion and OCD. A useful tool for this may be Rotter’s Internal-External (I-E) scale59 which measures the extent to which people believe they have control and determination over their lives (internal control) vs the degree to which they feel their destinies are beyond their personal control and are determined by fate, chance, or powerful others (external control). Counter to clinical intuition, a study60 using the I-E scale found that higher frequency of religious involvement correlated with internal LOC in Protestants and Jews, whereas the opposite was true in the Catholic sample. Analyzing these and other LOC findings may further identify contributory factors to the complex cognitive and affective systems impacting how OCD is experienced.
The lack of updated guilt measures, especially related to state- and trait-guilt, and the absence of OCD-specific guilt measures limited the ability of this review to more clearly operationalize factors involved in this construct. The creation of a reliable and valid research measure that delineates the effects of PG in OCD would be a valuable contribution to better understand and treat a meaningful, but often ignored, aspect of refractory symptoms within the standard OCD treatment framework.
Inaccessibility of pertinent archived theological literature (that would likely provide insights into historic formulations and ministrations of how obsessive guilt is addressed within the laity) is another limitation of this review. Likewise, the impact of historic psychological theories of guilt (ie, the psychoanalytic perspective of guilt/OCD serving as a defense mechanism against conflict between the superego and the id; and of guilt serving to defend the individual from acting on impulsive/aggressive urges) as contributors to the current OCD treatment culture was not discussed here. This was considered to be beyond the scope of the present review.
Based on collective clinical experience, and supported by the results of this review, further applied research of PG in OCD will better inform the field. Attention to this under-recognized and under-treated factor across OCD subtypes may subsequently improve treatment outcome. Emergent data may help to determine whether CBT strategies focused on PG have the potential to impact better treatment outcome and sustained recovery. The prevalence of PG in OCD could be determined through the development of valid assessment measures that identify the incidence of state- and trait-guilt for individual OCD clinical cases. Once this is established, differentially appropriate and effective CBT strategies may be developed to address the independent variables of state-guilt, trait-guilt, and any possible synergistic effects they may cause in refractory OCD cases.
OCD symptoms are clinically heterogeneous, but clinical experience in treating PG demonstrates that the individual’s response to his/her particular symptoms is more important than the symptoms themselves. We hypothesize that PG is not limited to the scrupulosity subtype, but occurs across almost all OCD subtypes. Development of evidence-based treatment strategies may result in a more robust treatment outcome for those who have been previously considered “treatment refractory.”
Whether guilt is a naturally selected evolutionary trait (reciprocal altruism)20 that keeps individuals safe from one another, whether it is a function of neurobiology, or whether it is conditionally learned from authority figures and/or one’s environment, it is clear that OCD further exploits those already vulnerable to guilt.
DISCLOSURES: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
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CORRESPONDENCE: Leslie J. Shapiro, LICSW, OCD Institute, McLean Hospital 115 Mill Street, Belmont, MA 02478 USA E-MAIL: firstname.lastname@example.org
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