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The Scrupulosity Obsessions and Compulsions Scale: A Measurement of Scrupulosity Within an OCD Framework
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Scrupulosity” is a common but understudied subtype of obsessive-compulsive disorder (OCD) characterized by religious obsessions and compulsions. Although scrupulosity is a common manifestation of OCD, it has not been adequately addressed in treatment studies. The aim of this study was to understand the conceptual nuances of scrupulosity, its diagnosis, the unique differences in conceptualization and interventions during its treatment, the specific tools needed to monitor the prognosis of the pathology, and the limitations of existing studies through a systematic review. Following PRISMA guidelines, a literature search was conducted, and 13 relevant studies were found in Google Scholar, Scopus, PubMed, EbscoHost + Ulakbim, Wiley Online Library, ScienceDirect, Taylor & Francis Online, and Web of Science databases. Two researchers independently rated the included articles using the MMAT and then met to compare the ratings. Disagreements were resolved through discussion and consensus was reached. There was a general lack of clarity in the conceptualization, diagnosis, and measurement of the severity of scrupulosity, and the content of religious or cultural interventions in the studies was not always clear. For future studies, further clarification, and systematization of the phenomenological features of scrupulosity and related epidemiological and empirical/experimental treatment research are needed.
Background
Due to the range of conflicting criteria regarding minimum sample size needed for a scale/questionnaire validation study, the objective of this review is to analyze sample sizes used in published journal articles to contribute a pragmatic perspective to the discussion on sample sizes.
Methods
A sample of 1999 articles published in a Scopus-indexed journal about the validation of a scale or questionnaire during 2021 were analyzed for this study. Abstracts from these articles were tabulated by two data entry professionals and any discrepancies were reviewed by the author. The sample size data was grouped by highest quartile of the journal publishing the article and further sub-categorized based on the inclusion of medical patients or students in each study’s population.
Results
From the total sample, 1750 articles provided sufficient information in their summary to determine the sample size used. Of these, the majority were published in quartile 1 (784) and quartile 2 (620) journals. Mean values by quartile ranged from 389 (quartile 3) to 2032 (quartile 1), but extreme outliers limited the usefulness of the simple mean. Thus, outlier-removed means were calculated, and in most cases, these sample size values were higher for studies involving students and lower for studies involving patients.
Discussion
This study is limited by its focus on a single database and by including all phases of validation from initial quantitative instrument design studies (which tend to have the lowest sample sizes) up to international macro-studies (which can have hundreds of thousands of participants.) Nevertheless, the results of this study provide an additional practical perspective for the academic discussion regarding minimum sample size based on accepted practice.
Individuals with obsessive-compulsive disorder (OCD) more often think about, attempt, and die by suicide than individuals from the general population. Sexual and religious obsessions (i.e., taboo obsessions) have been linked to increased risk of suicidality, but it is unclear if they explain additional risk over and above other risk factors. We refined the recently proposed multidimensional hierarchical model of OCD and explored how each symptom dimension in the model was associated with suicidality in a random half (n = 500) of a well-characterized cohort of patients with OCD. Symptom dimensions and other risk factors significantly associated with suicidality were included in a confirmatory multivariable model conducted with the other half of the sample (n = 501). The predictive confirmatory model accounted for 19% of the variance in suicidality. Taboo obsessions, the general OCD factor (i.e., having many different OCD symptoms at the same time), lifetime major depression, and lifetime substance use disorders significantly predicted suicidality in this model. Lifetime major depression explained most unique variance in suicidality (5.6%) followed by taboo obsessions and the general OCD factor (1.9% each). Taboo obsessions explain a small but significant proportion of variance in suicidality and should be considered an independent risk factor for suicidality in patients with OCD.
Scrupulosity is a form of OCD where patients obsess about morality and sometimes compulsively confess or atone. It involves chronic doubt and anxiety as well as deviant moral judgments. This chapter argues that Scrupulosity is a mental illness and that its distortion of moral judgments undermines, or at least reduces, patients’ moral responsibility. The authors go on to argue that this condition challenges popular deep-self theories of responsibility, which assert that one is only blameworthy or praiseworthy for actions that arise from one’s deep self, from what one truly values. Patients with ego-syntonic Scrupulosity, however, identify with their condition and seem to have cares that reflect their deep selves, yet do not seem fully responsible for their actions or their consequences, such as neglecting the needs of their loved ones. Other theories, particularly reasons-responsiveness theories, better capture the ways in which responsibility in Scrupulosity is reduced.
This study examined the relationships between perfectionism, scrupulosity, intrinsic spirituality, attachment to God, and psychological well-being among 547 members of The Church of Jesus Christ of Latter-day Saints (LDS). Maladaptive perfectionism was positively associated with scrupulosity and anxiety about God. Scrupulosity was positively associated with anxiety about God and avoidance from God. Intrinsic spirituality significantly mediated the link between scrupulosity and avoidance from God. Additional correlations are presented among maladaptive perfectionism, scrupulosity, anxiety about God, avoidance from God, and self-esteem. Implications for addressing maladaptive perfectionism, scrupulosity, attachment to God, and psychological well-being among a religious population are discussed.
In double barreled questions (DBQs) respondents provide one answer to two questions. Assumptions how respondents treat DBQs and how DBQs impact measurement quality are tested in two randomized experiments. DBQs are compared with revisions in which one stimulus was retained while the other stimulus was skipped. The observed means and parameters when modeling latent variables differed among the versions. Metric and scalar measurement invariance was not given among the versions, and at least one single stimulus version was found to be associated with a higher validity. Response latencies did not differ among versions or respondents needed less time to respond to DBQs. The author concludes that respondents may understand the stimuli in a DBQ differently, and access one of them while disregarding the other, which can have an adverse effect on validity.
Scrupulosity is a presentation of obsessive-compulsive disorder in which an individual’s obsessions and compulsions are related to religiosity. The Penn Inventory of Scrupulosity (PIOS), including the more recent Pennsylvania Inventory of Scrupulosity-Revised, has been widely used to assess levels of scrupulosity. The psychometric properties for this measure have been well established, and utility of the PIOS has been established across a variety of religious groups. However, the response style of atheists to the PIOS has yet to be examined. Consequently, the purpose of this study was to examine the psychometric properties of the PIOS in a sample of atheists relative to a sample of Christians. Based on a series of confirmatory factor analyses, the original two-factor model was found to be a poor fit with the data in both samples. Based on an exploratory factor analysis, a single-factor solution was retained in the Christian sample, which appears to assess a fear of God, punishment, and sinning. In the atheist sample, although a two-factor solution was originally observed, only one of the two factors appeared to be a viable subscale. This factor appears to assess a fear of immorality, and items on this subscale appear to be secular in nature. The findings and implications of the findings are discussed.
Across the landscape of mental health research and diagnosis, there is a diverse range of questionnaires and interviews available for use by clinicians and researchers to determine patient treatment plans or investigate internal and external etiologies. Although individually, these tools have each been assessed for their validity and reliability, there is little research examining the consistency between them in terms of what symptoms they assess, and how they assess those symptoms. Here, we provide an analysis of 126 different questionnaires and interviews commonly used to diagnose and screen for 10 different disorder types including depression, anxiety, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), addiction, bipolar disorder, eating disorder, and schizophrenia, as well as comparator questionnaires and interviews that offer an all-in-one cross-disorder assessment of mental health. We demonstrate substantial inconsistency in the inclusion and emphasis of symptoms assessed within disorders as well as considerable symptom overlap across disorder-specific tools. Within the same disorder, similarity scores across assessment tools ranged from 29% for assessment of bipolar disorder to a maximum of 58% for OCD. Furthermore, when looking across disorders, 60% of symptoms were assessed in at least half of all disorders illustrating the extensive overlap in symptom profiles between disorder-specific assessment tools. Biases in assessment toward emotional, cognitive, physical or behavioral symptoms were also observed, further adding to the heterogeneity across assessments. Analysis of other characteristics such as the time period over which symptoms were assessed, as well as whether there was a focus toward frequency, severity or duration of symptoms also varied substantially across assessment tools. The consequence of this inconsistent and heterogeneous assessment landscape is that it hinders clinical diagnosis and treatment and frustrates understanding of the social, environmental, and biological factors that contribute to mental health symptoms and disorders. Altogether, it underscores the need for standardized assessment tools that are more disorder agnostic and span the full spectrum of mental health symptoms to aid the understanding of underlying etiologies and the discovery of new treatments for psychiatric dysfunction.
Measures of traditional masculinity ideology (TMI) provide important information related to men’s well-being. However, most TMI measures are too long to be included in large public health, psychological, or medical survey batteries. Drawing on previous bifactor analyses of the Male Role Norms Inventory–Short Form (MRNI-SF), structural equation modeling (SEM) identified five items with variance primarily explained by a TMI general factor. These items formed the Male Role Norms Inventory–Very Brief (MRNI-VB), a unidimensional measure of the same TMI general factor captured by the MRNI-SF bifactor model. Several analyses were completed determining that the MRNI-VB performed as well as the original MRNI-SF. First, the unidimensional MRNI-VB evidenced equivalent fit to the bifactor MRNI-SF model in an archival sample of college and community men and women ( n = 6,744). Second, the MRNI-VB yielded statistically similar standardized beta coefficients to the MRNI-SF TMI general factor across 32 out of 38 regressions predicting variables within and outside of the MRNI nomological network in published ( n = 484) and unpublished ( n = 1,537) MRNI-SF research of college and community men. Third, in an unpublished sample of undergraduates who filled out the MRNI-VB instead of the entire MRNI-SF ( n = 365), the MRNI-VB yielded good model fit, good internal consistency reliability, and demonstrated a similar pattern of measurement invariance between men and women as the MRNI-SF. Overall, findings suggest that the MRNI-VB captures the same general TMI factor as the MRNI-SF but with a fraction of the items. Future directions, limitations, and implications are discussed.
Obsessive-compulsive disorder (OCD) is a phenomenologically heterogeneous disorder, and it has become increasingly important to understand symptom presentations cross-culturally. This chapter details differences and similarities in OCD symptoms in Western, Middle Eastern, Jewish, Hispanic, Asian, and other cultures. Research literature from several countries with distinct cultural backgrounds was systematically searched and reviewed, with critical points compiled and highlighted. Notable differences were found across cultures in symptom expression, obsessive cognitions, cultural influences on behavior, ritualistic beliefs, treatment-seeking behavior, and other issues. Differences included symptoms surrounding thought control, the relationship between beliefs, and cleaning and checking compulsions. Highly religious cultures emphasized purity, cleanliness, and religion as well as thought control, morality, and sexuality. Findings indicate that a culturally-informed approach may be needed to best understand the relationship between culture and OCD. Future research is needed to further explain and understand these differences.
Scrupulosity, or obsessive-compulsive symptoms related to religiosity or religion, is a common presentation of obsessive compulsive disorder (OCD), and it is important to elucidate its phenomenology and measurement. Today, the most widespread questionnaire for the assessment of scrupulosity is the Penn Inventory of Scrupulosity (PIOS). The current study examines the psychometric properties of the PIOS in outpatient, treatment-seeking patients. Results of a confirmatory factor analysis suggested an unsatisfactory fit for previously suggested factor structures. A follow-up exploratory factor analysis suggested that a bifactor model was the most suitable solution. In addition, the scores of the PIOS and its revised subscales were found to have moderate-good concurrent validity; however, its scores discriminated poorly between patients with scrupulous obsessions and patients with OCD and other repugnant obsessions. Group differences and receiver operating characteristics (ROC) analyses both indicated that the PIOS is more suitable in discriminating scrupulous obsessions in Christian patients but not in other religious groups (i.e., Jews, nonreligious patients). Additional analyses revealed that the co-occurrence of scrupulous and other repugnant obsessions is also moderated by religious affiliation. These results raise questions in terms of grouping scrupulosity with other repugnant obsessions and suggest for the need of culturally sensitive instruments of scrupulosity. (PsycINFO Database Record
This study examined the relationships and interactions between legalism, scrupulosity, family perfectionism, guilt, and shame among 421 Latter-Day Saints (LDS or Mormons). The results showed that scrupulosity fully mediated the links between legalism and guilt, as well as legalism and shame. A moderated-mediation effect was found, in which family discrepancy (maladaptive perfectionism) intensified the scrupulosity-shame association in the mediation model of legalism and shame by scrupulosity. Family discrepancy was not a significant moderator for the mediation model of legalism and guilt by scrupulosity. Additional results are provided and implications of these findings are outlined.
This study examined the relationships and interactions between religious commitment, perfectionism, scrupulosity, and psychological well-being among Latter-Day Saints (LDS or Mormons). The results showed a positive association between religious commitment and satisfaction with life. Scrupulosity partially mediated the relationship between maladaptive perfectionism and depression, anxiety, and satisfaction with life. The sample majority was classified as adaptive perfectionists, reporting higher intra-and interpersonal religious commitment, self-esteem, and satisfaction with life, and lower levels of anxiety and depression than the maladaptive and nonperfectionists. Additional results are provided. Implications of these findings are outlined.
Purpose:
New patient reported outcome (PRO) measures are regularly developed to assess various aspects of the patients' perspective on their disease and treatment. For these instruments to be useful in clinical research, they must undergo a proper psychometric validation, including demonstration of cross-sectional and longitudinal measurement properties. This quantitative evaluation requires a study to be conducted on an appropriate sample size. The aim of this research was to list and describe practices in PRO and proxy PRO primary psychometric validation studies, focusing primarily on the practices used to determine sample size.
Methods:
A literature review of articles published in PubMed between January 2009 and September 2011 was conducted. Three selection criteria were applied including a search strategy, an article selection strategy, and data extraction. Agreements between authors were assessed, and practices of validation were described.
Results:
Data were extracted from 114 relevant articles. Within these, sample size determination was low (9.6%, 11/114), and were reported as either an arbitrary minimum sample size (n = 2), a subject to item ratio (n = 4), or the method was not explicitly stated (n = 5). Very few articles (4%, 5/114) compared a posteriori their sample size to a subject to item ratio. Content validity, construct validity, criterion validity and internal consistency were the most frequently measurement properties assessed in the validation studies. Approximately 92% of the articles reported a subject to item ratio greater than or equal to 2, whereas 25% had a ratio greater than or equal to 20. About 90% of articles had a sample size greater than or equal to 100, whereas 7% had a sample size greater than or equal to 1000.
Conclusions:
The sample size determination for psychometric validation studies is rarely ever justified a priori. This emphasizes the lack of clear scientifically sound recommendations on this topic. Existing methods to determine the sample size needed to assess the various measurement properties of interest should be made more easily available.
Presently, the only clinically valid assessment of scrupulosity, an OCD subtype, is the Pennsylvania Inventory of Scrupulosity-Revised (PIOS-R; (B. Olatunji, Abramowitz, Williams, Connolly, & Lohr, 2007).To date, no study has evaluated the factor structure and diagnostic utility of this measure in a severe psychiatric sample. A clinical sample of 417 residential OCD patients with and without primary scrupulosity was assessed using the PIOS-R. A confirmatory factor analysis revealed that the previously-observed two-factor PIOS-R structure exhibited a good fit with these data. A receiver-operator characteristic (ROC) analysis indicated that the PIOS-R could reliably classify patients with clinically significant scrupulosity among the residential sample, with a score of 24 (out of 60) indicating the threshold of scrupulosity severity for which targeted treatment is warranted. These results indicate that the PIOS-R is a useful and appropriate measure for use in evaluating scrupulosity in patients with severe OCD.
Despite the widespread use of exploratory factor analysis in psychological research, researchers often make questionable decisions when conducting these analyses. This article reviews the major design and analytical decisions that must be made when conducting a factor analysis and notes that each of these decisions has important consequences for the obtained results. Recommendations that have been made in the methodological literature are discussed. Analyses of 3 existing empirical data sets are used to illustrate how questionable decisions in conducting factor analyses can yield problematic results. The article presents a survey of 2 prominent journals that suggests that researchers routinely conduct analyses using such questionable methods. The implications of these practices for psychological research are discussed, and the reasons for current practices are reviewed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The aim was to subject the Dimensions of Religiosity Scale to principal-components analysis in order to investigate the proposed component structure among a sample of 656 paticipants in England. Four components were identified, preoccupation, guidance, conviction, and emotional involvement. A main finding, however, was that the factor structure of the DR Scale was a function of the number of people in the sample who were religious.
This study sought to challenge the common conclusion that masculinity is only associated with decreased religiousness in men. The current investigation predicted more complex associations among these constructs, where both positive and negative associations would exist between masculinity and religiousness. To examine this, 154 male undergraduates completed a comprehensive measure of 11 masculine norms and measures of 5 aspects of religiousness: religious commitment; intrinsic, extrinsic, and quest religious motivations; and religious fundamentalism. Results indicated that both positive and negative associations exist between masculinity and religiousness. Three aspects of traditional masculinity (winning, power over women, and disdain for homosexuals) were positively correlated with various aspects of religiousness, and 3 aspects of traditional masculinity (emotional control, violence, and playboy) were negatively associated with various aspects of religiousness. Furthermore, 3 significant canonical functions were interpreted linking various aspects of masculinity to (a) traditional religiousness, (b) nondogmatic religiousness, and (c) both intrinsic and extrinsic religiousness. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This article reports on the validation of the Obsessive Beliefs Questionnaire (OBQ) and Interpretations of Intrusions Inventory (III) developed by the Obsessive Compulsive Cognitions Working Group (OCCWG) to assess the primary beliefs and appraisals considered critical to the pathogenesis of obsessions. A battery of questionnaires that assessed symptoms of anxiety, depression, obsessive-compulsive symptoms and worry was administered to 248 outpatients with a DSM-IV diagnosis of Obsessive-Compulsive Disorder (OCD), 105 non-obsessional anxious patients, 87 non-clinical adults from the community, and 291 undergraduate students. Tests of internal consistency and test-retest reliability indicated that the OBQ and III assessed stable aspects of un-related thinking. Between-group differences and correlations with existing measures of OC symptoms indicated that the OBQ and III assess core cognitive features of obsessionality. However, the various subscales of the OBQ and III are highly correlated, and both measures evidenced low discriminant validity. The findings are discussed in terms of the relevance and specificity of cognitive constructs like responsibility, control and importance of thoughts, overestimated threat, tolerance of uncertainty and perfectionism for OCD. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The Obsessive-Compulsive Inventory (OCI) is a new self-report instrument developed to address the problems inherent in available instruments for determining the diagnosis and severity of obsessive-compulsive disorder (OCD). The OCI consists of 42 items composing 7 subscales: Washing, Checking, Doubting, Ordering, Obsessing (i.e., having obsessional thoughts), Hoarding, and Mental Neutralizing. Each item is rated on a 5-point (0-4) Likert scale of symptom frequency and associated distress. One hundred and forty-seven individuals diagnosed with OCD; 58 with generalized social phobia; 44 with posttraumatic stress disorder; and 194 nonpatients completed the OCI and other measures of OCD, anxiety, and depression. The present article describes the psychometrics of the OCI including (a) scale construction and content validity, (b) reliability (internal consistency and retest reliability), and (c) convergent and discriminant validity. The OCI exhibited satisfactory reliability and validity with all 4 samples. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Scrupulosity is a form of obsessive-compulsive disorder (OCD) characterized by a tendency to have persistent doubts about God, sin, and the adequacy of one's religious behaviors and devotion. To date, no published studies have compared scrupulosity in high- and low-religious Muslim and Christian samples. In the present study religious school students as well as high- and low-religious university students in Turkey and Canada were compared on the Penn Inventory of Scrupulosity (PIOS), Obsessive Beliefs Questionnaire (OBQ-44), and symptom measures of obssesionality and negative affect. Between-group comparisons revealed that the highly religious Turkish sample scored significantly higher than the highly religious Canadian students on the PIOS Fear of God but not the Fear of Sin subscale. Separate multiple regression analyses revealed that the Clark-Beck Obsessive Compulsive Inventory (CBOCI) Obsessions subscale, OBQ-44 Importance and Control of Thoughts subscale, and guilt were significant unique predictors of PIOS scrupulosity. These findings suggest that subtle differences exist in how scrupulosity is manifested in Islamic and Christian believers.
Although several measures of obsessive-compulsive (OC) symptoms exist, most are limited in that they are not consistent with the most recent empirical findings on the nature and dimensional structure of obsessions and compulsions. In the present research, the authors developed and evaluated a measure called the Dimensional Obsessive-Compulsive Scale (DOCS) to address limitations of existing OC symptom measures. The DOCS is a 20-item measure that assesses the four dimensions of OC symptoms most reliably replicated in previous structural research. Factorial validity of the DOCS was supported by exploratory and confirmatory factor analyses of 3 samples, including individuals with OC disorder, those with other anxiety disorders, and nonclinical individuals. Scores on the DOCS displayed good performance on indices of reliability and validity, as well as sensitivity to treatment and diagnostic sensitivity, and hold promise as a measure of OC symptoms in clinical and research settings.
Recent factor-analytic studies in obsessive-compulsive disorder (OCD) identified consistent symptom dimensions. Support for the validity of these dimensions comes from studies of psychiatric comorbidity, functional brain imaging, genetic transmission, and treatment response to medications. This study examined whether previously identified OCD symptom dimensions are associated with treatment compliance and response to behaviour therapy (BT) for OCD.
One hundred and fifty-three OCD outpatients who participated in a multi-centre randomised controlled trial of computer- versus clinician-guided BT for OCD were included in the study. Logistic and multiple regression models tested for significant predictors of compliance with and response to BT and relaxation.
The patients studied were phenomenologically comparable (including the presence of 'pure' obsessions and mental rituals) to those in previous serotonin reuptake inhibitor (SRI) trials and those in clinical epidemiology studies. High scorers on the 'hoarding' dimension were more likely to drop out prematurely from the study and tended to improve less. For those completing treatment, the strongest predictor of outcome was pre-treatment severity. Initial depression scores were unrelated to outcome. After controlling for symptom severity, higher scores on the 'sexual/religious obsessions' factor predicted poorer outcome with BT, especially when computer-guided.
BT is especially indicated for OCD patients with aggressive/checking, contamination/cleaning and symmetry/ordering symptoms. Previous accounts of unsuccessful BT in patients with hoarding symptoms may be due in part to their propensity to drop out earlier from treatment. Patients with sexual/religious obsessions, but not those with mental rituals, might respond less well to traditional BT techniques. Existing treatments need to be refined and/or new treatments developed to improve these patients' adherence and response to treatment.
This article reports on the development of a revised version of the Obsessive-Compulsive Inventory (OCI; E. B. Foa, M. J. Kozak, P. Salkovskis, M. E. Coles, & N. Amir, 1998), a psychometrically sound, theoretically driven, self-report measure. The revised OCI (OCI-R) improves on the parent version in 3 ways: It eliminates the redundant frequency scale, simplifies the scoring of the subscales, and reduces overlap across subscales. The reliability and validity of the OCI-R were examined in 215 patients with obsessive-compulsive disorder (OCD), 243 patients with other anxiety disorders, and 677 nonanxious individuals. The OCI-R, which contains 18 items and 6 subscales, has retained excellent psychometric properties. The OCI-R and its subscales differentiated well between individuals with and without OCD. Receiver operating characteristic (ROC) analyses demonstrated the usefulness of the OCI-R as a diagnostic tool for screening patients with OCD, utilizing empirically derived cutscores.
The purpose of this study was to develop and provide a preliminary validation of a new measure of scrupulosity, the Scrupulous Thoughts and Behaviours Questionnaire (STBQ). More specifically, the STBQ was designed to assess a range of scrupulosity-related thoughts/obsessions and behaviours/compulsions. Following item development, a sample of non-referred college students completed the STBQ along with numerous validation measures. Based on factor analyses, a two-factor solution was retained. The first factor consisted of items that measure scrupulosity-themed obsessions and thoughts, and the second factor consisted of items that measure scrupulosity-themed compulsions and related behaviours. Support was found for the validity of STBQ, as both subscales were significantly and positively associated with measures of relevant constructs, including the Pennsylvania Inventory of Scrupulosity-Revised, the only other self-report measure of scrupulosity, thought–action fusion, religiosity, and obsessive–compulsive disorder symptoms. As the first known self-report measure to assess scrupulosity obsessions and compulsions, the STBQ has a potential utility in clinical practice and research.
Scrupulous obsessions are a prominent presentation of obsessive-compulsive disorder (OCD). Previous conceptualizations of scrupulosity have indicated that it belongs to the unacceptable thoughts dimension, which pertains to sexual, violent, and religious obsessive themes. However, research suggests that scrupulous symptoms may differ from other unacceptable thoughts symptoms, necessitating the need for targeted and thorough assessment. We added a Scrupulous or Religious Thoughts subscale (DOCS-SR) to the Dimensional Obsessive-Compulsive Scale (DOCS) and tested its factorial structure, psychometric properties, and clinical correlates in a non-clinical and clinical sample. In the first study, non-clinical participants (N = 203) completed the DOCS-SR, which was subjected to an exploratory factor analysis. Analyses revealed that the DOCS-SR reflected a one-factor solution and possessed acceptable internal consistency, as well as strong convergent validity with clinical correlates of OCD. In the second study, we administered the DOCS, as well as the DOCS-SR to a clinical sample (N = 314). An exploratory factor analysis and confirmatory factor analysis both suggested that the four subscales and additional DOCS-SR represented a five-factor solution. Internal consistency and convergent validity were strong. The DOCS Unacceptable Thoughts subscale and the DOCS-SR shared a moderate correlation but evidenced differences in associations with other correlates. This suggested both convergent and divergent validity. Collectively, our results support the utility of examining the individual components of the unacceptable thoughts dimension of OCD for effective assessment and treatment planning.
This commentary provides a brief mathematical review of exploratory factor analysis, the common factor model, and principal components analysis. Details and recommendations related to the goals, measurement scales, estimation technique, factor retention, item retention, and rotation of factors. For researchers interested in attempting to identify latent factors, exploratory factor analysis, the common factor model, is the appropriate analysis. For surveys with Likert-type scales weighted least squares with robust standard errors is recommended along with oblique rotation. Alternative techniques for analyzing the data, e.g., item response theory and machine learning, are briefly discussed. Finally, a basic check list for researchers and reviewers is provided.
Objective
Scrupulosity is a manifestation of obsessive‐compulsive disorder (OCD) characterized by religious or moral core fears. Clinicians often struggle to treat scrupulosity, which may be associated with several features known to predict poor treatment outcome. The purpose of this study was to examine these features in participants with scrupulous OCD, contamination OCD, and healthy controls.
Method
A total of 68 participants (57.4% women, agemean = 34.01) completed diagnostic interviews, and measures of symptoms and quality‐of‐life.
Results
Relative to comparison groups, scrupulous participants had higher rates of obsessive‐compulsive personality disorder, more severe schizotypal symptoms, and more severe symptoms of depression. In addition, OCD severity was strongly associated with poor insight in the scrupulous group. Both OCD groups reported poorer quality of life than did healthy controls.
Conclusions
Clinicians working with scrupulous individuals may enhance the efficacy of treatment in this challenging population by assessing carefully for these features, and incorporating treatment elements that address them.
Background:
Scrupulosity is a common yet understudied presentation of obsessive compulsive disorder (OCD) that is characterized by obsessions and compulsions focused on religion. Despite the clinical relevance of scrupulosity to some presentations of OCD, little is known about the association between scrupulosity and symptom severity across religious groups.
Aims:
The present study examined the relationship between (a) religious affiliation and OCD symptoms, (b) religious affiliation and scrupulosity, and (c) scrupulosity and OCD symptoms across religious affiliations.
Method:
One-way ANOVAs, Pearson correlations and regression-based moderation analyses were conducted to evaluate these relationships in 180 treatment-seeking adults with OCD who completed measures of scrupulosity and OCD symptom severity.
Results:
Scrupulosity, but not OCD symptoms in general, differed across religious affiliations. Individuals who identified as Catholic reported the highest level of scrupulosity relative to individuals who identified as Protestant, Jewish or having no religion. Scrupulosity was associated with OCD symptom severity globally and across symptom dimensions, and the magnitude of these relationships differed by religious affiliation.
Conclusions:
Findings are discussed in terms of the dimensionality of scrupulosity, need for further assessment instruments, implications for assessment and intervention, and the consideration of religious identity in treatment.
The Penn Inventory of Scrupulosity (PIOS) is the most widely utilised measure of religious obsessive-compulsive disorder. While it has been studied in clinical and community samples, its psychometric properties have not been evaluated among highly religious Orthodox Jewish individuals. This is consequential, as scrupulosity is most likely to occur in religious contexts. In two studies, we examined its factorial structure, reliability, and concurrent validity among: (1) Jewish community members and (2) a small sample of Orthodox Jewish patients presenting for anxiety treatment. Results suggest that it is a reliable and valid psychometric tool that primarily reflects scrupulosity and anxiety, even among devoutly religious Jews. However, the measure may also capture some aspects of normative religiosity among both Orthodox and non-Orthodox community members. Nevertheless, results suggest that the PIOS has research and clinical validity and utility even among the pious, although caution should be utilised in interpreting scores from highly religious samples.
Previous studies suggest that the link between obsessive–compulsive (OC) symptoms and moral thought–action fusion (TAF) depends on religion; however, no study has compared Muslim and Jewish samples. We examined the relationships between OC symptoms, scrupulosity, religiosity, and moral TAF in Israeli Muslims and Jews. Religiosity was not associated with elevations in OC symptoms, although religiosity correlated with scrupulosity across the entire sample after controlling for depression and anxiety. Moral TAF was related to scrupulosity across the entire sample. The Muslim group had higher levels of OC symptoms, scrupulosity, and depressive symptoms than did the Jewish group, but the groups were equally religious. In addition, Muslims scored higher than did Jews on moral TAF even after controlling for symptoms; however, moral TAF was not related to scrupulosity within the Muslim group. In combination, these results imply that moral TAF depends on cultural and religious factors and does not necessarily indicate pathology.
Obsessive-compulsive disorder is a severe and disabling clinical condition that usually arises in late adolescence or early adulthood and, if left untreated, has a chronic course. Whether this disorder should be classified as an anxiety disorder or in a group of putative obsessive-compulsive-related disorders is still a matter of debate. Biological models of obsessive-compulsive disorder propose anomalies in the serotonin pathway and dysfunctional circuits in the orbito-striatal area and dorsolateral prefrontal cortex. Support for these models is mixed and they do not account for the symptomatic heterogeneity of the disorder. The cognitive-behavioural model of obsessive-compulsive disorder, which has some empirical support but does not fully explain the disorder, emphasises the importance of dysfunctional beliefs in individuals affected. Both biological and cognitive models have led to empirical treatments for the disorder-ie, serotonin-reuptake inhibitors and various forms of cognitive-behavioural therapy. New developments in the treatment of obsessive-compulsive disorder involve medications that work in conjuction with cognitive-behavioural therapy, the most promising of which is D-cycloserine.
• The Yale-Brown Obsessive Compulsive Scale was designed to remedy the problems of existing rating scales by providing a specific measure of the severity of symptoms of obsessivecompulsive disorder that is not influenced by the type of obsessions or compulsions present. The scale is a clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4 (extreme symptoms) (total range, 0 to 40), with separate subtotals for severity of obsessions and compulsions. In a study involving four raters and 40 patients with obsessive-compulsive disorder at various stages of treatment, interrater reliability for the total Yale-Brown Scale score and each of the 10 individual items was excellent, with a high degree of internal consistency among all item scores demonstrated with Cronbach's α coefficient. Based on pretreatment assessment of 42 patients with obsessive-compulsive disorder, each item was frequently endorsed and measured across a range of severity. These findings suggest that the Yale-Brown Scale is a reliable instrument for measuring the severity of illness in patients with obsessive-compulsive disorder with a range of severity and types of obsessive-compulsive symptoms.
Sample size guideline for exploratory factor analysis (EFA) was long established however none investigate the effect from the difference of measurement scales. The authors are concern if researchers prefer to use the minimum number of sample size from the guideline in conducting EFA especially in the clinical setting since it is difficult to get enough sample size. Here, the authors present a guideline of sample size requirement according to various types of measurement scales and also suggest guideline if any researcher planned to apply the rule of thumb that proposes the smallest number of sample size for EFA.
Analogue samples are often used to study obsessive-compulsive (OC) symptoms and related phenomena. This approach is based on the hypothesis that results derived from such samples are relevant to understanding OC symptoms in individuals with a diagnosis of obsessive-compulsive disorder (OCD). Two decades ago, Gibbs (1996) reviewed the available literature and found initial support for this hypothesis. Since then there have been many important advances addressing this issue. The purpose of the present review was to synthesize various lines of research examining the assumptions of using analogue samples to draw inferences about people with OCD. We reviewed research on the prevalence of OC symptoms in non-clinical populations, the dimensional (vs. categorical) nature of these symptoms, phenomenology, etiology, and studies on developmental and maintenance factors in clinical and analogue samples. We also considered the relevance of analogue samples in OCD treatment research. The available evidence suggests research with analogue samples is highly relevant for understanding OC symptoms. Guidelines for the appropriate use of analogue designs and samples are suggested.
We addressed the question of whether the bi-factor or higher-order model is the more appropriate model of human cognitive ability structure. In previously published nested confirmatory factor analyses, the bi-factor model tended to be better fitting than the higher-order model; however, these studies did not consider a possible inherent statistical bias favouring the fit of the bi-factor model. In our own analyses and consistent with previous empirical results, the bi-factor model was also better fitting than the higher-order model. However, simulation results suggested that the comparison of bi-factor and higher-order models is substantially biased in favour of the bi-factor model when, as is commonly the case in CFA analyses, there is unmodelled complexity. These results suggest that decisions as to which model to adopt either as a substantive description of human cognitive ability structure or as a measurement model in empirical analyses should not rely on which is better fitting.
Sexual and religious obsessions are often grouped together as unacceptable thoughts, symptoms of obsessive-compulsive disorder (OCD) hypothesized to be maintained by maladaptive beliefs about the importance and control of thoughts. Although there is empirical justification for this typology, there are several reasons to suspect that sexual and religious obsessions may differ with respect to associated obsessional beliefs and personality traits. In this study, we examined the associations between sexual and religious obsessions (separately) and (a) putatively obsessional cognitive styles, especially beliefs about the importance and control of thoughts, and responsibility; (b) obsessive-compulsive personality traits; and (c) schizotypal personality traits. Whereas sexual obsessions were predicted only by increased beliefs about the importance and control of thoughts, and contamination obsessions were predicted only by inflated responsibility appraisals and threat estimation, religious obsessions were independently predicted by both of these constructs. In addition, only religious obsessions were related to self-reported obsessive-compulsive personality traits. Researchers and clinicians should be cognizant of potentially important distinctions between sexual and religious obsessions, and the possibility that scrupulous OCD shares processes with both autogenous and reactive presentations.
Background:
Several studies have identified discrete symptom dimensions in obsessive-compulsive disorder (OCD), derived from factor analyses of the individual items or symptom categories of the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC). This study aims to extend previous work on the relationship between obsessions and compulsions by specifically including mental compulsions and reassurance-seeking. Because these compulsions have traditionally been omitted from prior factor analytic studies, their association to what have been called "pure obsessions" may have been overlooked.
Method:
Participants (N = 201) were recruited from two multi-site randomized clinical treatment trials for OCD. The YBOCS-SC was used to assess OCD symptoms, as it includes a comprehensive list of obsessions and compulsions, arranged by content category. Each category was given a score based on whether symptoms were present and if the symptom was a primary target of clinical concern, and a factor analysis was conducted. Mental compulsions and reassurance-seeking were considered separate categories for the analysis.
Results:
Using an orthogonal geomin rotation of 16 YBOCS-SC categories/items, we found a five-factor solution that explained 67% of the total variance. Inspection of items that composed each factor suggests five familiar constructs, with mental compulsions and reassurance-seeking included with sexual, aggressive, and religious obsessions (unacceptable/taboo thoughts).
Conclusions:
This study suggests that the concept of the "pure obsessional" (e.g., patients with unacceptable/taboo thoughts yet no compulsions) may be a misnomer, as these obsessions were factorially associated with mental compulsions and reassurance-seeking in these samples. These findings may have implications for DSM-5 diagnostic criteria.
Cognitive-behavioral therapy by exposure and response prevention (EX/RP) is an effective treatment for obsessive-compulsive disorder (OCD). However, patients who have religious obsessions and compulsions (scrupulosity) introduce concerns not commonly encountered when treating individuals with other types of OCD symptoms. The present case history describes the successful use of EX/RP for a patient with scrupulosity. Behavioral and cognitive symptoms of OCD responded to treatment and remained improved at 6-month follow-up. Special considerations in presenting the rationale for using exposure-based interventions, and in developing exposure exercises for these types of symptoms, are discussed in detail.
The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed.
The attitudes of Catholicism and Judaism to scrupulosity are presented and the similarity between their management programmes and present-day behavioural psychotherapy is noted. Two famous cases are presented from 16th-century Europe and a further four cases from our 20th-century clinic in Jerusalem. Certain common features are noted, typical of obsessive-compulsive disorders, while some features, typical of scrupulosity, are best understood by considering both their religious and psychological importance.
The objective of this study was to examine the long-term course of obsessive-compulsive disorder (OCD) in patients treated with serotonin reuptake inhibitors (SRIs) and behavioral therapy and to identify predictors of clinical outcome.
Sixty outpatients meeting DSM-II-R or DSM-IV criteria for OCD were followed up for 1 to 5 years (mean = 2.5 years). All of them received prolonged pharmacologic therapy with an SRI.
Thirty-seven patients (61.7%) completed an adequate behavioral treatment. At long-term assessment, 22 patients (36.7%) exhibited a global Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score greater than 16 or a final reduction in Y-BOCS global score of less than 35% and were considered nonresponders. Patients who completed behavioral therapy showed a significant decrease in Y-BOCS compulsions subscale score (p = .01), whereas no significant differences in either Y-BOCS global or obsessions subscale scores between those who did and those who did not undergo behavioral therapy were detected. Obsessions of sexual/religious content were the unique factor related to a poorer long-term outcome.
A substantial number of OCD patients showed persistent disabling symptoms at the long-term follow-up in spite of combined pharmacologic and behavioral treatment. Major benefits from behavioral therapy appeared to be the improvement of ritualistic behaviors. Sexual/religious obsessions predicted poorer long-term outcome, whereas short-term response to SRI treatment failed to achieve predictive value in the long-term course of OCD.
Religion has often been thought to play a part in the genesis of some cases of obsessive-compulsive disorder (OCD). In this study, we explored the relationship between religiosity, religious obsessions, and other clinical characteristics of OCD. Forty-five outpatients with OCD were evaluated with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Yale-Brown Obsessive-Compulsive Checklist (Y-BOCC) as well as the Religious Practices Index (RPI), which was developed for this study. On the basis of these evaluations, 42% of the patients were found to have religious obsessions. Despite differences in the frequency of religious obsessions found in this study compared with others, a factor analysis revealed the symptom dimensions to be similar to those found in other OCD samples. There was no significant difference in the overall severity of obsessions and compulsions between patients with and without religious obsessions. RPI scores did not differ significantly between groups. We failed to find a relationship between RPI scores or religious obsessions and any particular type of obsession or compulsion. A logistic regression analysis revealed that the sole predictor of the presence of religious obsessions was a higher number of types of obsessions. In conclusion, we failed to find a conclusive relationship between religiosity and any other clinical feature of OCD, including the presence of religious obsessions. On the other hand, we showed that the patients who tend to have a variety of obsessions are more likely also to have religious obsessions. Thus, religion appears to be one more arena where OCD expresses itself, rather than being a determinant of the disorder.
The present investigation reports on the development and psychometric evaluation of the Penn Inventory of Scrupulosity (PIOS), a 19-item self-report scale measuring religious obsessive-compulsive symptoms. Factor analysis yielded a two factor solution with the first subscale measuring fears about having committed sin, and the second measuring fears concerning punishment from God. Using a sample of college students, the PIOS was shown to be internally consistent and possess good convergent and discriminant validity. Highly devout participants evidenced higher scores on both PIOS subscales, but devout Jews evidenced fewer fears of sin and punishment from God compared to devout Protestants or Catholics. The PIOS has utility both as a research and clinical tool.