Mental Illness

Scrupulosity is a mental illness. This is not determined simply by inclusion in or exclusion from the current DSM. The features that characterize Scrupulosity needn’t be disordered, and this chapter addresses skepticism—eliminativism and social constructionism—about mental illness more generally. Illnesses, according to skeptics about mental illness, require physical markers and a value-free diagnosis. These are not present for Scrupulosity, nor are they present for many mental illnesses. The chapter considers dysfunction and harm as definitive of mental illness. It then examines the DSM-5 definition of mental illness and finds that Scrupulosity fits that definition.

Responsibility

Responsibility admits of degrees, and Scrupulosity seems to diminish responsibility for harms caused to some degree. We focus on whether Scrupulosity provides an excuse that reduces or removes moral liability responsibility for bad actions or consequences. More precisely, we distinguish attributability, answerability, and accountability responsibility. Our question is whether someone with Scrupulosity is accountability responsible—whether it is fitting to feel anger, resentment, or indignation toward them—for harms they cause. We consider two compatibilist theories of responsibility: deep-self theories and reasons-responsiveness theories. Unlike deep-self theories, reasons-responsiveness theories can distinguish scrupulous actions by distinguishing responding to reasons from responding to anxiety. Finally, we address whether present responsibility can be traced to one’s previous bad decisions and cases in which one was clearly responsible.

Character and Virtue

Scrupulosity is not religious devotion or moral virtue. Those with Scrupulosity are concerned with moral behavior primarily as a way to reduce their underlying doubts and anxiety. Moral character requires attention to, concern for, and responsiveness to the morally relevant features of situations, acts, and people. Moral character also requires a stable set of underlying traits and beliefs that noncoincidentally lead to the appropriate motivations and endorsements. Some with Scrupulosity are ego-dystonic, rejecting their scrupulous symptoms, but one might also reject one’s own character. Those whose Scrupulosity is ego-syntonic—who endorse their scrupulous symptoms—also differ from those with moral character because those with Scrupulosity display fixation on certain issues to the exclusion of others, are inflexible with respect to circumstances, are overly concerned with merely possible—not probable—events, have an inflated sense of personal responsibility, and care about moral issues for the wrong reasons.

Cases

This chapter presents several cases of Scrupulosity that are revisited throughout the book. The cases raise questions almost immediately: Why are these people like this? Do they really believe what they say? Are they mentally ill or mistaken? If they’re mentally ill, what is wrong with them? If they’re mistaken, what are they mistaken about? Cases of Scrupulosity are contrasted with other cases of extreme moral or religious concern. The disorder Scrupulosity is distinguished from nonclinical scrupulous behavior and the question is raised of how to categorize a particular case. The method of starting with cases to build a characterization of Scrupulosity is defended in the following chapters.

Introduction

Morality is central to our lives and regulates our behavior even absent external punishment or reward. Because morality is complicated, it is best studied from multiple perspectives and disciplines. We here propose studying morality from the perspective of psychiatry. Moral psychiatry, as we call this new subfield, focuses on mental illnesses whose content is closely related to morality, using psychiatric conditions to illuminate morality. This ultimately sheds light on ordinary moral functioning without unrealistically idealizing our psychology. Scrupulosity is an example of how psychiatric conditions can illuminate morality and test philosophical theories in various ways.

Scrupulosity as a Form of OCD

Scrupulosity is closely connected to OCD, despite some appearances and informal characterizations of Scrupulosity as a concern with sin. Those with Scrupulosity have obsessions and/or compulsions. The Penn Inventory of Scrupulosity-Revised (PIOS-R) captures the religious features of Scrupulosity. A secular presentation is less common or has been diagnosed less often, but a non-religious presentation is still possible. The distinctive features of Scrupulosity are perfectionism, chronic doubt and intolerance of uncertainty, and moral thought-action fusion. None of these features are exclusive to Scrupulosity, but they mutually reinforce each other and together characterize the condition.

Obsessive-Compulsive Disorder

Scrupulosity dates back millennia and is widely reported in Catholic and Protestant traditions over the last half-century. This chapter looks more generally at obsessive-compulsive disorder (OCD). OCD is characterized by obsessions and compulsions. Obsessions are recurrent and persistent, intrusive and unwanted, unjustified, and anxiety-evoking. Also, OCD needs to be distinguished from a different condition with a similar name: obsessive-compulsive personality disorder (OCPD). Whereas OCD is an anxiety disorder, OCPD is a personality disorder, that is, a disorder in those stable traits that make up one’s personality. The chapter addresses difficulties in determining whether obsessions are beliefs: normal tests of beliefs fail in the case of OCD and Scrupulosity. It next considers compulsions, repetitive behaviors performed in response to obsessions that aim to prevent or reduce anxiety or distress.

Epilogue

Philosophical reflections on Scrupulosity have revealed several important complexities about morality, religion, sainthood, character, mental illness, responsibility, and rationality. In particular, they have shown how mental illness is much more complicated than just the absence of rationality, that moral actions, character traits, and moral judgments cannot be evaluated in isolation but must be considered in context. This larger context is conveyed in therapy. The goal here was not to resolve these complexities but to illustrate how these issues are illuminated by reflecting about real psychiatric cases. These cases and reflections are instructive about how hard and sometimes subtle it is to draw a clear line between this disorder and ordinary, rational moral life.

Treatment

We are sometimes justified in encouraging, pressuring, or requiring those with Scrupulosity to seek treatment, even if they object on moral grounds. The justification for treating OCD does not apply to Scrupulosity. Possible justifications for treatment over moral objection are harm to self or others, distress, future gratitude, community treatment standards, and internal incoherence of one’s beliefs due to arbitrariness, conflation, or fixation. All of these justifications avoid explicit appeals to the therapist’s own moral standards. Some forms of treatment raise no distinctive moral issues, but some raise ethical issues because they require the person to do things the person considers immoral. This can be alleviated in part by good communication with the therapist about the point of such treatment.

Moral Judgments

Scrupulous moral judgments vary from moral judgments made by those without Scrupulosity. The content of Scrupulous moral judgments are perfectionist, which conflates what is ideal with what is obligatory, conflates the moral evaluation of thoughts and actions, and is influenced by chronic doubt and intolerance of uncertainty. Anxiety motivates Scrupulous moral judgments. Scrupulosity is both judgment-driven—one’s judgments evoke anxiety—and anxiety-driven—anxiety prompts rationalizing judgments and even causes beliefs. Anxiety leads to systematic distortions in one’s moral judgments. Anxiety leads one to act in a way that soothes one’s anxiety. Genuine moral judgments respond to all morally relevant features, not just a narrow set thereof. Anxiety narrows one’s attention, often to features that are not the most morally relevant, and is unresponsive to counterevidence. Scrupulous moral thought leads to excessive precision and to focus on features that rationalize one’s anxiety.