A variety of factors contribute to the development of scrupulosity OCD. In this chapter I review age, gender, and genetic contributions. I also review biological, cognitive, affective, and social contributions. In the next chapter I will discuss behavioral features that contribute to the development, as well as maintenance, of scrupulosity.

Age and Gender

To understand age- and gender-based research on scrupulosity, we first turn to the general OCD data, as scrupulosity is a form of OCD. OCD tends to begin during two developmental periods. Studies differ on the exact age of onset, but the first period, referred to as early onset, is prepubertal and generally occurs in late childhood or early adolescence. The second period, referred to as late onset, generally occurs in the late teens to early twenties.[1] Studies have consistently reported that males are more likely to develop early-onset OCD than females.[2] However, this gender difference balances out with people who develop OCD later in life, with males and females being equally as likely to develop the disorder. Early onset of OCD is also associated with greater comorbidity (overlap with other disorders), an increased familial pattern for OCD, and, frequently, the sufferer’s absence of insight into the nature of the problems.[3] In OCD studies men tend to be more likely to have a higher frequency of religious obsessions than do women.[4]

In scrupulosity-specific OCD studies, no significant differences were found in the research between men and women relative to scrupulosity severity.[5] Scrupulosity was found to be mildly associated with age; older college students reported less scrupulosity. Those who struggled with significant reassurance-seeking behaviors were significantly younger than were those without reassurance-seeking behaviors.

Genetics

Twin studies and family studies examining genetic contributions to OCD strongly suggest that vulnerability to OCD can be inherited. Rates of OCD heritability range between 45 and 65 percent,[6] with higher rates of family OCD being found in early-onset individuals. For late-onset OCD, a positive family history is absent in many patients. However, there isn’t an OCD gene. The genetic component to OCD that gets passed on seems to be a general predisposition for anxiety, and then that familial “anxiety-proneness” interacts with other factors contributing to OCD.[7]

In reference to the development of various forms of OCD, including scrupulosity, there is no biological explanation for why one person develops one form of OCD while another person develops another.[8]

Biological Explanations of OCD

Most of the OCD research examines the biomedical aspects of the disorder. “Prevailing theories indicate that OCD is a biological disease.”[9] The biological or neuroanatomical perspective of OCD validates the premise that scrupulosity is not about inefficient willpower, lack of moral discipline, or a fractured faith. Many researchers have contributed to the theory that OCD involves “dysfunction in a neuronal loop running from the orbital frontal cortex to the cingulate gyrus, striatum (caudate nucleus and putamen), globus pallidus, thalamus and back to the frontal cortex.”[10] Damage to these areas of the brain causes obsessive-compulsive symptoms, offering supporting evidence for this model.

Yet the science is far from settled—does OCD cause differences in the brain, or does the brain look different because the person has OCD? Some findings and theories follow:

• Intrusive thoughts may be accounted to a striatal dysfunction, mainly of the caudate nucleus (an important part of the brain’s learning and memory system).
• Inefficient thalamic gating seen in OCD may contribute to the sticky thoughts as thoughts are allowed to cycle through the gate around and around, again and again and again.[11]
• Abnormalities in the basal ganglia, a set of subcortical nuclei in the cerebrum largely responsible for motor control, motor learning, executive functions and behaviors, emotions, and awareness of thoughts, may be a primary site of dysfunction. This condition has been shown to be associated with the OCD severity and may impact the effectiveness of certain medications.[12]
• Hyperactivity of the orbital cortex (the underside of the front part of the brain above the eye sockets) may contribute to an explanation for OCD’s intrusive thoughts. In OCD this orbital cortex is hypermetabolic, meaning it is overheated in people with OCD (because it is working too hard).“The person with OCD can’t get rid of those intrusive thoughts and urges because the circuit from the orbital cortex, the brain’s ‘early-warning detection system,’ is firing inappropriately.”[13] This hypermetabolic activity has been shown to decrease following treatment.[14] Exposure and response prevention causes therapeutic changes in the left orbitofrontal cortex.[15]
• Non-specific anxiety (an overall sense of dread that something’s wrong and you need to fix it) may be caused by the cingulate gyrus (just above the corpus callosum). It is the part of the cortex involved in processing emotions and regulating behavior and is the cause for that “something catastrophic is going to happen” feeling. “Before treatment, the cingulate gyrus is tightly locked to the orbital cortex, which is probably the reason why obsessive thoughts and urges are accompanied by such terrible feelings of dread.”[16]
• The neurotransmitter serotonin may be abnormally active in those that are suffering from OCD.[17] This belief arose from observations that clomipramine, which inhibits the reuptake of both serotonin and norepinephrine, relieved obsessive-compulsive symptoms, whereas noradrenergic reuptake inhibitors did not. This hypothesis is supported by the efficacy of medications such as clomipramine and other selective serotonin reuptake inhibitors (SSRIs). (Yet the improvement noted by these medications does not prove that these abnormalities cause OCD,[18] and research has shown that the serotonin system seems to work appropriately in people with OCD. So it is now believed that this theory is incorrect.)[19]

Cognitive Processes

Anxiety sensitivity

Given that anxiety lies at the heart of scrupulosity, it is important to note that some people are more likely to develop anxiety disorders than others. They may experience more worry, may be more perfectionistic, and so on. One contributing factor to OCD is anxiety sensitivity, a tendency to misinterpret the physical symptoms of anxiety as imminently threatening or harmful. With anxiety sensitivity, people fear their own internal reactions more than actual circumstances. They’re afraid of their anxiety, or as we might say, they have anxiety about having anxiety. Anxiety is uncomfortable, triggering all sorts of physiological reactions that make your body feel wonky. It is unsettling (and outright miserable at higher levels). Some are overly sensitive to that internal experience and get anxious about anything that might trigger those kinds of physical sensations. Research has shown that those high in anxiety sensitivity are five times more likely to develop anxiety disorders, especially a panic disorder.[20]

The cognitive perspective helps to explain how people may process information in this manner. They can “be exquisitely sensitive to occasional unwanted, yet normally occurring, unpleasant intrusive thoughts with religious themes.”[21] Thus, that sensitivity contributes to misinterpretations of threat associated with these naturally occurring religious intrusive thoughts. This causes an increase in distress and futile efforts to remove the intrusion and reduce obsessional distress.

Information processing[22]

Information processing relates to how information is received and processed. Since anxiety distorts the processes around gathering and storing information, those with anxiety see and remember things differently than do those without anxiety.[23] In anxiety disorders such as scrupulosity, the distortion skews consistently toward anxiety’s negative bias, whereas people without anxiety show an opposite bias.

There is significant evidence that people with generalized anxiety have selective attention for threat-related information. For example, “socially anxious individuals have an attentional bias favouring social-threat stimuli, such as angry faces and social-threat words.”[24] From an information-processing perspective, this means that people struggling with anxiety are primed to be hypervigilant, looking for threat; they are going to notice potential dangers or threats more readily than may someone without anxiety. Anxious people are drawn to threatening information, dwell on it longer than do others, and tend to interpret information in a threatening way when information is ambiguous. This means they have selective attention due to anxiety’s negative bias and then have a harder time ignoring it.[25] This includes intolerance of uncertainty, fear of the unknown, and persistent thoughts about the unknown. Intolerance of uncertainty then causes more intolerance of uncertainty, and so on.[26]

Cognitive domains of OCD

Research has identified three cognitive domains common in OCD. [27] These domains affect the development of one’s intellectual knowledge and skills, as well as the processing and evaluation of information:

1. Responsibility and threat estimation: an over inflated sense of responsibility leads to obsessions about harm (either causing harm or the need to prevent it).
2. Perfectionism and intolerance for uncertainty: many OCD patients believe if they can minimize mistakes, they can reduce uncertainty.
3. Importance and control of thoughts: overvaluing anxiety-triggering thoughts often leads those with OCD to seek ways to control these thoughts.[28] One study examined cognitive styles in scrupulosity using an Iranian Muslim population and found that scrupulosity was particularly associated with the overvaluation of thoughts and the need for controlling thoughts.[29]

Cognitive processes

In addition to these general OCD cognitive domains, a variety of cognitive processes are specific to scrupulosity:[30]

1. There are dysfunctional thought patterns (such as moral thought-action fusion, to be discussed in chapter 7) surrounding moral issues and religious themes. These dysfunctional thought patterns escalate feelings of guilt.
2. There are frequent periods of confusion or doubt regarding possible sins or broader concerns of morality. This confusion interferes with one’s ability to think clearly and rationally about a given concern. Reassurance from others doesn’t help.
3. There are generally long periods of rumination analyzing a current concern or mentally reviewing and agonizing over past indiscretions. As discussed in chapter 3, this is not obsessing about intrusive thoughts (which are out of conscious control) but a conscious exercise trying to “figure it out.” The longer one ruminates, the more anxious and confused one tends to become.
4. Those suffering with scrupulosity tend to interpret ambiguous stimuli in the most threatening manner possible. The anxiety has a negative bias, continuously evaluating for threat, and makes negative interpretations according to that bias. This becomes particularly problematic in religious and moral issues: “Religious principles are characteristically expressed in sweeping and ambiguous terms and moral injunctions are often deliberately designed to overstate a principle for hyperbolic or metaphorical effect. When a negative cognitive style collides with these types of statements, the fundamental message can be so rigidly or literally interpreted that it often becomes a radical source of anxiety and further confusion.”[31]
5. Those with scrupulosity become fixed on religious or moral issues. What may be seen as a nonissue to those without OCD may become a major religious or moral crisis for the one with scrupulosity. Everything is a moral dilemma! This significantly escalates anxiety in daily life.
6. There are misperceptions that are often accompanied by poor insight and awareness. Sufferers may not understand why they are so anxious or what it is they really fear. A tendency toward poor awareness may be due in part to their overwhelming worry over religious and moral issues. Thus overwhelmed and not in their window of tolerance, they are not capable of fully processing their thoughts.
7. Those with scrupulosity may also experience derealization and depersonalization. Derealization is a sense of being disconnected from one’s reality, while depersonalization is a sense of disconnect from personal identity or from experiencing one’s body in an accurate way.

Affective processes

From an affective (emotional) perspective, scrupulosity stems from pathological anxiety. In a seeming contradiction to anxiety’s generally future orientation, scrupulosity frequently draws people into torment about past violations of moral or religious tenets (possible, imagined, or actual). Yet it is the focus on how those past sins may affect their future that may be the focus of their obsessions. The uncertainty often creates feelings of depression such as hopelessness, emotional numbing, apathy, and anhedonia (loss of interest or pleasure in activities once found enjoyable).[32] One person with this disorder wrote, “Uncertainty ate away at my sanity, and I thought I was going to have a nervous breakdown at any second.”[33]

Social features

Social support and interconnectedness are important components of mental health. At times, those suffering with scrupulosity may choose to engage socially and benefit from social support, which can prove to be therapeutic. However, due to the emotional distress of the disorder, those with scrupulosity may often choose to isolate. Separating from family and friends contributes to a reinforcement of dysfunctional thoughts and behaviors. Without social checks and balances in place, it becomes more difficult to discern what is real and dysfunction can grow.

It is also possible that, their own desires to socialize notwithstanding, others may withdraw from the person trapped in the scrupulous cycle due to the strain of the reassurance-seeking behaviors. In a study examining Catholic priests’ understanding of scrupulosity, one priest commented about a woman suffering with scrupulosity: “People are not going to communicate with her, she’s going to get more isolated, she’s going to spend more of her time going into herself and turning it all over in her mind, and so it is all sort of compounded.”[34]

In addition, scrupulosity strains the person’s relationship with religious authority. In a study examining ultraorthodox rabbis’ experiences with scrupulous parishioners, a rabbi commented, “When I answer such a person, he keeps debating, raising some far-fetched scenarios which perhaps I haven’t considered. He jumps from one subject to another, forcing me to repeat my answers again and again. You can see that the person is trapped in some kind of mechanism.”[35] Another rabbi described how he was not being listened to: “I was doing my utmost to answer the questions of such a person, but it felt that he was caught in his own thoughts, repeatedly asking the same questions I just answered, at times with minor changes without even considering my advice.”[36]

Additionally, due to the social nature of religious worship and other religious activities, scrupulosity often makes it difficult for people to participate appropriately in their religious community. In a study of Muslim women, researchers commented that one could speculate that in a religious society like that of the Saudis, where a lot of community activities revolve around religious rituals, the women’s “lives must have been severely disrupted by their illness not only because they were not able to fulfil God’s demands, but also because they were failing to fulfil their function in their society.”[37]

This social strain can be particularly salient for religious missionaries as they work to teach religious principles while often living away from home with an assigned companion. One client commented on this social strain, “Believing that I was experiencing religious OCD was difficult on my mission. I was suffering immensely, and I was in no way mentally healthy. Many companions did not have the social or emotional acumen to adequately process and respond to my experiences with OCD. Some companions judged and shamed me for my experiences. I felt confused and trapped.”

Notes

[1] Del Casale, A. etal (2019). Psychopharmacological treatment of obsessive-compulsive disorder (OCD). Current Neuropharmacology, 17(8), 710–736. https://doi.org/10.2174/1570159X16666180813155017

[2] Mathes, B. M., Morabito, D. M., Schmidt, N. B. (2019). Epidemiological and clinical gender differences in OCD. Current Psychiatry Reports, 21(5). https://doi.org/10.1007/s11920-019-1015-2.

[3] Keeley, M. L., Storch, E. A., Merlo, L. J., Geffken, G. R. (2008). Clinical predictors of response to cognitive-behavioral therapy for obsessive-compulsive disorder. Clinical Psychology Review, 28(1),119–120.https://doi.org/10.1016/j.cpr.2007.04.003

[4] Shapiro, L. J. (2020). Obsessive compulsive disorder: Elements, history, treatments, and research. Praeger, 20.

[5] Olatunji, B. O., Abramowitz, J. S., William, N. L., et al (2007). Scrupulosity and obsessive-compulsive symptoms: Confirmatory factor analysis and validity of the Penn Inventory of Scrupulosity. Journal of Anxiety Disorders, 21(6), 784.

[6] Shapiro, 2020. Obsessive compulsive disorder, 17–18.

[7] Abramowitz, J. S. (2018). Getting over OCD: A 10-step workbook for taking back your life (2nd ed.). Guilford Press, 30.

[8] Schwartz, J. M., & Beyette, B. (1996). Brain lock: Free yourself from obsessive-compulsive behavior. HarperPerennial, xliv.

[9] Stanford Medicine. (n.d.). Understanding obsessive-compulsive and related disorders. https://med.stanford.edu/ocd/about/understanding.html

[10] Stanford Medicine. Understanding obsessive-compulsive and related disorders.

[11] Schwartz Beyette, 1996. Brainlock, 51.

[12] Shapiro, 2020. Obsessive compulsive disorder, 114.

[13] Schwartz & Beyette, 1996. Brain lock, 51.

[14] Stanford Medicine. Understanding obsessive-compulsive and related disorders.

[15] Shapiro, L. J. (2015). Understanding OCD: Skills to control the conscience and outsmart obsessive compulsive disorder. Praeger, 107C.

[16] Schwartz & Beyette, 1996. Brain lock, 52.

[17] Osborn, I. (2008). Can Christianity cure obsessive-compulsive disorder? A psychiatrist explores the role of faith in treatment. Brazos Press, 120.

[18] Stanford Medicine. Understanding obsessive-compulsive and related disorders.

[19] Abramowitz, 2018. Getting over OCD, 30; emphasis in original.

[20] Maller, R. G., Reiss, S.(1992). Anxiety sensitivity in 1984 and panic attacks in 1987. Journal of Anxiety Disorders, 6(3), 241–247. https://doi.org/10.1016/0887-6185(92)90036-7

[21] Olatunji et al., 2007. “Scrupulosity and obsessive-compulsive symptoms,” 784; emphasis added.

[22] See discussion in Giles, G., & Densley, S., Jr. (2018, August). Barriers to belief: Mental distress and disaffection from the church. https://www.fairlatterdaysaints.org/conference/august-2018/barriers-to-belief

[23] Yiend, J., & Mackintosh, B. (2004). Experimental modification of processing biases. In J. Yiend (Ed.), Cognition, emotion and psychopathology: Theoretical, empirical and clinical directions. Cambridge University Press, 190.

[24] Mogg, K., Bradley, B. P. (2004). A cognitive-motivational perspective. In Yiend, Cognition, emotion and psychopathology, 74.

[25] MacLeod, C. etal. (2004). Causal status of biases. In Yiend, Cognition, emotion and psychopathology, 173.

[26] Carleton, R.N. (2012, August). The intolerance of uncertainty construct in the context of anxiety disorders: Theoretical and practical perspectives. Expert Review of Neurotherapeutics,12(8),937–947.

[27] Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part 1,” Behaviour Research and Therapy, 41(8), 863–878. https://doi.org/10.1016/s0005-7967(02)00099-2. Part 2: Factor analyses and testing of a brief version,” Behaviour Research and Therapy, 43(11), 1527–1542. https://doi.org/10.1016/j.brat.2004.07.010

[28] Obsessive Compulsive Cognitions Working Group, 2005. Psychometric validation of the obsessive belief questionnaire: Part 2, 1536–1537.

[29] Kaviani, S., Hossein, E., & Soghra, E. G. (2015). The relationship between scrupulosity, obsessive-compulsive disorder and its related cognitive styles. Practice in Clinical Psychology, 3, 47–59.

[30] For a more in-depth discussion of these seven points, see Miller, C. H., Hedges, D. W. (2008). Scrupulosity disorder: An overview and introductory analysis. Journal of Anxiety Disorders, 22(6), 1044–1046. https://doi.org/10.1016/j.janxdis.2007.11.004

[31] Miller & Hedges, 2008. Scrupulosity disorder, 1045.

[32] Miller & Hedges, 2008. Scrupulosity disorder, 1046.

[33] Ferguson, K. (2017). The OCD Mormon: Finding healing and hope in the midst of anxiety. Cedar Fort, 7.

[34] Hepworth, M., Simonds,L. M., Marsh, R. (2010). Catholic priests’ conceptualization of scrupulosity: A grounded theory analysis. Mental Health, Religion & Culture,13(1),7.

[35] Horwitz, B., Littman, R., Greenberg, D., Huppert, J. D. (2019). A qualitative analysis of contemporary ultra-orthodox rabbinical perspectives on scrupulosity. Mental Health, Religion & Culture, 22, 88.

[36] Horwitz et al., 2019. Contemporary ultra-orthodox rabbinical perspectives on scrupulosity, 88.

[37] Al-Solaim, L. & Loewenthal, K. M. (2011). Religion and obsessive-compulsive disorder (OCD) among young Muslim women in Saudi Arabia. Mental Health, Religion & Culture, 14(2), 180. https://doi.org/10.1080/13674676.2010.544868