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. Author manuscript; available in PMC: 2024 Oct 1.
Published in final edited form as: J Trauma Stress. 2023 Aug 31;36(5):932–942. doi: 10.1002/jts.22961

Fear of Sin and Fear of God: Scrupulosity Predicts Women’s Daily Experiences of Mental Contamination Following Sexual Trauma

Alyssa C Jones 1,2, Jordyn M Tipsword 3, C Alex Brake 4, Emily E Fenlon 3, Thomas G Adams Jr 3, Jesse P McCann 3, Christal L Badour 3
PMCID: PMC10591805  NIHMSID: NIHMS1934020  PMID: 37653683

Abstract

Mental contamination refers to feelings of dirtiness in response to thoughts, images, or memories. Mental contamination is frequently reported after sexual trauma and associated with symptoms of posttraumatic stress disorder (PTSD). Differences in individuals’ views about morality and purity may influence the severity of mental contamination, though has been studied outside of samples assessed for PTSD. The present study addressed this gap by investigating scrupulosity as a prospective predictor of daily sexual trauma-related mental contamination and PTSD symptoms. Participants included 40 adult women with a history of sexual trauma and current sexual trauma-related mental contamination who completed baseline diagnostic interviews and questionnaires followed by two assessments every day for two weeks. Results indicated that scrupulosity was positively correlated with severity of PTSD symptoms and sexual trauma-related mental contamination at baseline. Scrupulosity was also a prospective predictor of increased daily sexual trauma-related mental contamination but not daily PTSD symptom severity. Findings indicate that scrupulosity may be an important factor for understanding recovery from sexual assault.

Keywords: Scrupulosity, Mental Contamination, PTSD, Sexual Trauma

Perceptions of responsibility and self-blame are common reactions to sexual trauma and are considered risk factors for the development and maintenance of posttraumatic stress disorder (PTSD; Kline et al., 2021). PTSD involves distressing intrusive thoughts, images, and sensations related to the trauma, negative alterations in cognitions and mood, avoidance, and hyperarousal (American Psychiatric Association [APA], 2013). Longitudinal research indicates that blaming oneself for behavior at the time of a trauma predicts PTSD symptom severity in the first month after sexual assault, after which PTSD symptoms predict self-blame in the following two to four months (Kline et al., 2021). These results underscore the role of self-blame in the initial aftermath of trauma in predicting more severe PTSD, highlighting the importance of understanding factors that may lead to more intense self-blame. Shame and guilt, which result from perceptions of blame and responsibility, are common after sexual trauma and associated with more severe PTSD (Cunningham, 2020). Furthermore, trauma-related shame and guilt appear to predict PTSD symptom change in treatment (Øktedalen et al., 2015). Despite advances in PTSD treatment, one study found that roughly half the women who completed Prolonged Exposure or Cognitive Processing Therapy for sexual assault-related PTSD continued to report ongoing difficulties with self-blame or self-hate (Larsen et al., 2019). Additional research focused on factors that influence self-blame, shame, and guilt may inform the etiology of PTSD and provide targets for improving PTSD treatments.

In contrast to the sizable body of literature on self-blame, shame, and guilt within PTSD, fewer studies have assessed contamination or dirtiness after trauma, despite their frequent co-occurrence with trauma-related shame and guilt (Brake et al., 2021; Jones & Badour, 2023). Sexual trauma survivors may report feeling dirty in response to thoughts or memories of the trauma (i.e., mental contamination) even years after it has occurred (Fairbrother & Rachman, 2004; Rachman, 2004). Trauma-related mental contamination may emerge due to feelings of disgust when recalling contact with potential contaminants during the trauma (e.g., blood, semen, saliva), as well as a sense of physical, emotional, or moral violation (e.g., perceptions of immorality, betrayal, and humiliation; Coughtrey et al., 2014a; Olatunji et al., 2008; Rachman, 2004). Whereas contact contamination involves experiences of dirtiness that arise during or immediately following exposure to a physical pollutant and are specific to the point of contact, mental contamination is elicited by thoughts, images, or memories even in the absence of contact with a physical contaminant (Coughtrey et al., 2014a, 2014b; Rachman, 2004; Waller & Boschen, 2015). Although both physical and mental contamination may elicit urges to wash or clean, distress from mental contamination appears more resistant to washing than contact contamination, which can often be alleviated or substantially reduced by washing or cleansing behaviors (Coughtrey et al., 2014a; Waller & Boschen, 2015).

Mental contamination has been consistently and positively associated with PTSD symptoms, particularly after sexual assault (Adams et al., 2014; Badour, Feldner, Babson et al., 2013; Badour, Feldner, Blumenthal, & Bujarski, 2013; Ishikawa et al., 2015). In fact, PTSD symptoms appear to predict greater increases in disgust, feelings of dirtiness, and urges to wash in response to trauma memories among women with a history of sexual assault, but not among those with a history of non-sexual assault (Badour, Feldner, Babson et al., 2013). This suggests that the association between mental contamination and PTSD symptoms may be of greater relevance to sexual trauma than other trauma types. Despite the persistence of mental contamination and its robust, positive association with PTSD symptoms, relatively little is known about why some individuals may be more prone to experience mental contamination after sexual trauma compared to others.

In addition to event-specific factors (e.g., exposure to contaminants, injury severity, closeness to perpetrator; Pinciotti et al., 2022), feelings of dirtiness after sexual trauma may also result from attitudes about modesty and chastity; sometimes referred to as “purity culture” (Owens et al., 2020). Purity culture is rooted in heteronormative gender roles and often involves an emphasis on virginity (particularly among women), the prohibition of physical affection, the need for modesty, sexual gatekeeping, denial of women’s bodily autonomy, and a lack of education on sexual consent (Owens et al., 2020; Natarajan et al., 2022). The emphasis on modesty often conveys the idea that women must dress in a way to protect men from lust and sin, as men are viewed as having less self-control over sexual desires (Owens et al., 2020). As a result of sexual gatekeeping responsibilities and a lack of education on sexual consent, purity culture may place women at higher risk for feeling responsible for preventing any sexual encounters, including sexual assault (Barker & Galliher, 2020; Owens et al., 2020). Although purity culture can be found in both religious and secular cultural settings, it is particularly emphasized within some religious communities (Barker & Galliher, 2020; Klein, 2018). A study of self-identified Christian men and women found that those with stronger purity culture beliefs were more likely to hold beliefs consistent with rape myths (Owens et al., 2020), which suggests positive associations between purity culture and victim-blaming attitudes.

In addition to the potential for victim-blaming, purity culture may also predispose individuals to feel physically and morally contaminated after sexual activity. It is not uncommon to encounter metaphors equating certain sexual activities with impurity; for instance, some religious groups have compared a woman who engages in premarital sex with chewed gum full of saliva or a tissue full of mucus and snot (Klein, 2018), implying that a woman’s body is contaminated and inherent worth is lost after sexual activity. Unsurprisingly, such teachings may influence how women process unwanted sexual experiences (Barker & Galliger, 2020). Chen et al. (2013) found that female undergraduate students with no stated religious affiliation who received objectifying comments about their bodies from an alleged male reported feeling more sinful and endorsed a stronger desire to buy cleansing products compared to participants who did not receive objectifying comments. Furthermore, participants who viewed the physical objectification as their responsibility were more likely to feel contaminated and sinful, demonstrating an association between self-blame and feeling sinful and dirty. Another study found that perceptions of responsibility after an imagined nonconsensual kiss predicted feelings of dirtiness, urges to wash, and negative emotions (e.g., shame, guilt) in a female undergraduate sample, and those who endorsed more shame and guilt after the imagined nonconsensual kiss were more likely to engage in actual washing behaviors (Radomsky and Elliot, 2009). A limitation of these studies, however, is the inability to determine why some individuals felt more responsible than others. It is possible that perceptions of self-blame and impurity are more prevalent among individuals with more concerns about their own sin and immorality, such as those endorsing greater levels of scrupulosity.

Scrupulosity (“fearing sin where there is none”) is conceptualized as obsessive-compulsive distress driven by beliefs about religion and morality (Abramowitz & Jacoby, 2014, p. 140). Scrupulosity has traditionally been viewed as a subtype of obsessive-compulsive disorder (OCD; Olatunji et al., 2007) and involves fear that one has or will commit a sin, fears of upsetting God or being punished by God, or intrusive mental images deemed blasphemous (e.g., destroying a religious text; Abramowitz et al., 2002). Scrupulosity-related obsessions may motivate compulsive behaviors that impede healthy, adaptive religious practice, including excessive praying, repeating religious rituals until completed “perfectly,” or excessive reassurance seeking from religious leaders (Abramowitz & Hellberg, 2020; Huppert & Siev, 2010) as well as excessive avoidance of religious or moral triggers (e.g., avoiding religious services or texts; Abramowitz & Hellberg, 2020; Olatunji et al., 2007). Though typically related to a patient’s religious practices, some patients may present with a more secular scrupulosity driven by strict adherence to socially constructed rules (Huppert & Siev, 2010).

Scrupulosity and mental contamination may be functionally linked given their overlapping features and predictors (e.g., moral purity). Fergus (2014) first demonstrated such an association by showing a positive cross-sectional association between scrupulosity and mental contamination (r = .69, p < .01) among a community sample of self-identifying Catholic and Protestant adult men and women. Furthermore, mental contamination was robustly associated with scrupulosity even after accounting for overall religiosity, negative affect, and obsessive-compulsive symptom severity. Fergus (2014) postulated that scrupulosity may cause individuals to misinterpret or appraise intrusive thoughts as immoral or impure, which could lead to or be exacerbated by mental contamination. Others have also theorized that cleaning and washing behaviors among patients with high scrupulosity beliefs may represent efforts to achieve or recover moral purity (Olatunji et al., 2007). Although scrupulosity was not assessed, one study of Muslim undergraduate students examined the indirect effect of religious fundamentalism (i.e., the tendency to strictly follow religious principles) on urges to wash after an imagined nonconsensual kiss scenario. Results showed an indirect effect such that stronger fundamentalist religious beliefs were associated with a stronger urge to wash through more intense mental contamination and negative emotions (Inozu et al., 2022). Notably, scrupulosity research has been conducted predominantly outside of samples that were assessed for trauma or PTSD.

Although washing, cleaning, and other compulsive behaviors may be used to reduce feelings of dirtiness, research suggests they may maintain this distress (Coughtrey et al., 2014a). Extending these findings, it is plausible that individuals with more fears about immoral or sinful thoughts or behaviors (i.e., greater scrupulosity) may be more likely to experience mental contamination from trauma-related intrusive thoughts, images, or memories, and therefore engage in compulsive behaviors (e.g., excessive cleaning, washing, praying, confession) to recover a sense of cleanliness, purity, or morality. Although compulsive behaviors may provide immediate relief, by serving as forms of avoidance and escape these behaviors ultimately maintain mental contamination, other trauma-related emotions (e.g., disgust, shame, guilt), and the continued use of compulsions to manage distress. This process may also maintain or worsen PTSD symptoms by impeding corrective learning and inhibiting the natural decay of negative emotions (Coughtrey et al., 2014a; Steil et al., 2011).

In sum, extant literature suggests positive associations between scrupulosity and mental contamination (Fergus, 2014), yet no studies have examined these constructs within a trauma-exposed sample to test whether scrupulosity is a vulnerability factor for more severe trauma-related mental contamination and PTSD symptoms among individuals exposed to sexual trauma. To address this gap in the literature, the present study investigated associations between scrupulosity, sexual trauma-related mental contamination, and PTSD symptoms among a community sample of women with a history of sexual trauma. It was predicted that baseline scrupulosity would be positively associated with baseline sexual trauma-related mental contamination and PTSD symptoms. It was also predicted that baseline scrupulosity would prospectively predict increased daily sexual trauma-related mental contamination and PTSD symptoms. Specific facets of scrupulosity—fear of sin and fear of God—were predicted to demonstrate a similar pattern and prospectively lead to increased daily sexual trauma-related mental contamination and PTSD symptoms.

Method

Participants

The current study included secondary analysis from a larger study focused on understanding sexual trauma-related mental contamination (Brake et al., 2021). Participants included community-recruited adult women with a history of sexual trauma and current sexual trauma-related mental contamination (defined as scoring ≥ 10 on the Posttraumatic Experience of Mental Contamination scale [PEMC; Brake et al., 2019] and endorsing current sexual trauma-related mental contamination during a clinical interview). Given that a primary study goal was to study the relationship between scrupulosity and sexual trauma-related mental contamination, and so little is known about this relationship, the sample was not limited to only those with PTSD. This decision was made in order to preserve as much range as possible to avoid artificially restricting the range of symptoms and missing potentially important variability in the primary variables. After a preliminary phone screen, 54 individuals were enrolled in the study. Of these individuals, 10 endorsed no current sexual trauma-related mental contamination during the clinical interview and were thus ineligible to continue. Data from two male participants were excluded because of low male participation. Data from one participant was excluded because of incomplete diagnostic interviews, and another participant was excluded because they did not complete the scrupulosity measure. This resulted in a final sample of 40 women aged 18 to 57 years (M = 32.9, SD = 12.6). Participants identified as White (72.5%), Black/African American (20.0%), Multi-racial (5.0%), or another race not listed (2.5%). Additionally, 10.0% of participants identified as Hispanic. Participants identified as heterosexual (70.0%), bisexual (22.5%), gay/lesbian (5.0%), or another sexual orientation not listed (2.5%). Most participants had completed some college at minimum (92.5%). Income ranged from < $20,000 to > $100,000, with 47.5% of the sample endorsing < $20,000.

Procedure

All study procedures were approved by the University of Kentucky Nonmedical Institutional Review Board. Flyers, brochures, and internet postings were placed around local businesses, public gathering spaces, and online to recruit participants. Community members who previously reached out to the laboratory and expressed interest in enrolling in future studies were also contacted. Those who were interested completed a pre-enrollment phone screen. Enrolled participants completed the following during the study: 1) pre-visit online self-report questionnaires; 2) a laboratory visit involving interviews, additional online questionnaires, and instruction in how to complete daily diary assessments; and 3) two weeks of twice-daily assessments on a smartphone application.

The web-based survey builder Qualtrics was used to administer pre-visit self-report questionnaires. Daily survey ratings were administered with the LifeData app that was installed on participants’ smartphones or to a device loaned out for purposes of the study. The two-week assessment period started the day after the laboratory visit. Participants were notified via timed reminders in the morning (9:00 a.m.) and evening (5:00 p.m.) to complete daily assessments (as described in the Measures section), consistent with prior research in similar daily assessment contexts (Possemato et al., 2012, 2015). Assessments were to be completed within a 4-hour window, and participants received electronic reminders every 30 minutes. Assessments were skipped if they were not filled out within this window. To improve adherence, study personnel contacted participants if they did not complete the morning and evening assessments for at least half of the first week of assessments, or if they failed to complete four consecutive assessments at any point throughout the study.

Each participant was compensated $30 upon completing the in-person laboratory visit and were given referrals for mental health and crisis services. Participants earned $1 for each of the 28 daily assessments completed, and $5 bonuses for each time four consecutive responses were logged.

Measures

Baseline measures

Sexual trauma history

Items from the National Stressful Events Survey (NSES; Kilpatrick et al., 2011) were used to assess participants’ sexual trauma history. These items included three behaviorally specific yes/no questions evaluating lifetime history of childhood sexual contact, unwanted sexual contact under force or threat of force, and unwanted sexual contact while under the influence of alcohol or drugs. Individuals endorsed at least one of these items to achieve initial study eligibility.

PTSD symptoms

Baseline past-month PTSD symptom severity was measured using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, Schnurr et al., 2013), a semi-structured clinical interview evaluating the intensity and frequency of DSM-5 defined PTSD symptoms. PTSD symptoms were anchored to a participant’s most distressing experience of sexual trauma (i.e., the index trauma), which was identified by the participant at the beginning of the interview. Symptoms were rated on a scale of 0 (absent) to 4 (extreme/incapacitating), and a total score was achieved by summing scores for each of the 20 symptoms (possible range: 0-80). Higher scores indicate more severe symptoms, and scores of 23 to 34 reflect moderate symptom severity (Weathers et al., 2018). CAPS-5 scores were also used to determine DSM-5 PTSD diagnostic status using the SEV2 rule (Weathers et al., 2018). A trained graduate student conducted each interview, and 20% were selected at random and coded for interrater reliability using Cohen’s Kappa for diagnostic reliability (κ = 1.0). Agreement on total PTSD symptom severity was excellent (average r = .98). Scores on the CAPS-5 have shown good convergent and discriminant validity in prior studies (Weathers et al., 2018); internal consistency in the current study was good (α = .81).

Sexual trauma-related mental contamination

The 20-item Posttraumatic Experience of Mental Contamination scale (PEMC; Brake et al., 2019) was used to assess sexual trauma-related mental contamination. The PEMC is a self-report questionnaire based on the Vancouver Obsessional Compulsive Inventory-Mental Contamination scale (VOCI-MC; Radomsky et al., 2014). The VOCI-MC measures trait mental contamination (e.g., “I often feel dirty under my skin”), whereas the PEMC assesses mental contamination following a traumatic experience (e.g., “Since the traumatic event, I often feel dirty under my skin”). In the current study, participants were asked to focus on the index sexual trauma when responding to PEMC items. Participants then rated each item on a five-point Likert-type scale (0 = not at all to 4 = very much); higher scores reflected more severe sexual trauma-related mental contamination (possible range: 0-80). A score of 10 or greater was used as the cutoff for eligibility in the current study, consistent with past studies using a cutoff of 10 on the VOCI-MC to demonstrate moderate mental contamination in non-clinical samples (Coughtrey et al., 2014a, 2014b). The PEMC demonstrates a single factor structure, strong internal consistency, and strong convergent validity with the VOCI-MC, as well as incremental utility over the VOCI-MC in predicting posttraumatic stress and obsessive-compulsive symptoms (Brake et al., 2019). Reliability for the PEMC in the current study was excellent (α = .92).

Two items from Fairbrother and Rachman’s (2004) sexual assault-related mental contamination interview were also administered during the laboratory visit (“What, if anything, brings back that feeling of dirtiness now?”; “What about memories of the unwanted sexual experience, do they bring back that feeling of dirtiness?”) to confirm current experiences of sexual trauma-related mental contamination. Negative responses to both of these items indicated ineligibility to participate in remaining study activities (i.e., the daily assessments) after the lab visit.

Scrupulosity

Scrupulosity was measured using the 15-item Penn Inventory of Scrupulosity-Revised (PIOS-R; Olatunji, et al., 2007). The PIOS-R uses a five-point Likert-type scale (0 = never to 4 = constantly) in which participants rated current scrupulosity beliefs. The PIOS-R has two subscales measuring fear of sin (“I feel urges to confess sins over and over again;” 10 items) and fear of God (“I am afraid my behavior is unacceptable to God;” 5 items). Items were summed to create a total severity rating, and higher scores indicated greater scrupulosity beliefs (possible range: 0-60). Scores of 24 and higher reflect a clinical severity that potentially warrants treatment (Shapiro et al., 2013). Scores on the PIOS-R have demonstrated satisfactory convergent and divergent validity, and research has demonstrated psychometric support for both the total scrupulosity score and subscale scores (Olatunji et al., 2007). Scores in the current study exhibited excellent internal consistency (α = .92-.95 for the total score and subscales).

Daily assessments

Sexual trauma-related mental contamination

Daily sexual trauma-related mental contamination was measured using an adaptation of the 15-item State Mental Contamination Scale (SMCS; Lorona et al., 2018). The SMCS (rather than the PEMC) was used to measure daily sexual trauma-related mental contamination because it has established psychometric support for assessing daily/state mental contamination in both lab-based and ecological research (Lorona et al., 2018). Similar to the PEMC, the SMCS was remodeled from the VOCI-MC to frame questions in a current context (e.g., VOCI-MC: “I often feel dirty under my skin”; SMCS: “I feel dirty under my skin”). Using a five-point Likert-type scale (0 = not at all to 4 = very much), participants rated each item producing total scores ranging from 0 to 60, with higher scores reflecting more severe state mental contamination. For the current study, SMCS instructions were modified to assess mental contamination experiences related to participants’ index trauma since their last daily assessment. The SMCS has shown excellent internal consistency and good convergent and discriminant validity (Lorona et al., 2018). In the current study, excellent reliability was observed over 28 assessments (between-person; Rkf = .99), and reliability of change (within-person; Rc = .95) was also achieved.

PTSD symptoms

Daily PTSD symptoms were assessed with an adaptation to the 20-item PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz, Keane et al., 2013), a self-report questionnaire measuring PTSD symptoms. The adapted version measured PTSD symptoms related to participants’ index sexual trauma (as discussed during their CAPS-5 interview) since the most recent daily diary prompt (e.g., “Since the last assessment, how much have you been bothered by repeated, disturbing, and unwanted memories of the stressful experience?”). Participants completed items on a five-point Likert-type scale (0 = not at all to 4 = extremely), and responses were summed to produce a total PTSD symptom score at each timepoint (possible range: 0-80). Higher PCL-5 scores reflect greater PTSD symptom severity. Past studies using daily diary methods to assess PTSD symptoms have shown the utility of this adapted form of symptom reporting (Dworkin et al., 2017; Black et al., 2016; DeViva et al., 2020). Excellent reliability estimates were achieved in the current study for both between-person difference (Rkf = .99) and within-person change (RC = .92).

Data Analysis

All analyses were conducted using IBM SPSS Statistics (Version 27; IBM Corp., 2020). Descriptive analyses examined frequencies or means and standard deviations of study variables. To address cross-sectional hypotheses, bivariate correlations examined associations among baseline scores for primary study variables. Primary analyses involved a series of multilevel linear models with restricted maximum likelihood estimation to account for the nested structure of daily assessments within participants. This approach allows for simultaneous between- and within-individual effect estimates and accounts for autocorrelation of non-independent data points within individuals, as well as varying intervals due to potential missing data points (Krull & MacKinnon, 2001; Snijders & Bosker, 2012). First, intercepts and slopes of change in daily mental contamination and PTSD symptoms from the first to the last day of the daily assessments were examined using conditional random intercept and slope multilevel linear models with time coded in hours (−160 to 160) and whether the day was a weekday or weekend (Monday through Friday = 0, Saturday/Sunday = 1) to determine if average scores on either of these variables changed systematically across the 14-day period, and if average scores on either of these variables differed during the week versus weekend. Given that the present study was a secondary data analysis, a-priori power analyses were unable to be conducted. However, a sensitivity analysis was conducted using Murayama et al.’s (2022) web app to determine the smallest effect size the study was powered to detect. According to the analysis, assuming alpha = .05 and no cross-level interactions, with N = 40 we had 80% power to detect ds > .45.

Conditional multilevel linear models with random intercepts and slopes were used to identify whether a) total scores on the PIOS or b) PIOS subscales (PIOS-fear of God, PIOS-fear of sin) prospectively predicted severity of daily sexual trauma-related mental contamination or daily PTSD symptoms. Baseline measures of sexual trauma-related mental contamination (PEMC) and PTSD symptoms (CAPS-5) were included as covariates.

Results

Descriptive statistics

Of the total sample, 67.5% (n = 27) met criteria for PTSD. The mean level of scrupulosity in this sample (M = 25.60, SD = 14.87) was above the clinical severity cut off of 24 as determined by Shapiro et al. (2013); 57.5% (n = 23) of participants in the present study scored 24 or higher on the PIOS-R. Results of independent samples t-tests among those with and without PTSD demonstrated that there was a significant difference in baseline sexual trauma-related mental contamination, t(38) = −2.65, p = .012, between those with PTSD (M = 53.85; SD = 12.83) compared to those without PTSD (M = 41.69; SD = 15.14). There was not a significant difference in baseline scrupulosity, t(34.93) = −1.57, p = .125, between those with PTSD (M = 27.78; SD = 16.35) versus without PTSD (M = 21.08; SD = 10.34). However, consistent with hypotheses, total scrupulosity and fear of sin were moderately positively correlated with baseline PTSD symptom severity and sexual trauma-related mental contamination. Fear of God was significantly correlated with baseline sexual trauma-related mental contamination, but not baseline PTSD symptom severity. Means, standard deviations, and correlations among study variables at baseline are shown in Table 1.

TABLE 1.

Descriptive statistics and intercorrelations among study variables at baseline

Variable M SD 1. 2. 3. 4. 5.
1. Baseline PTSD symptoms (CAPS-5) 31.45 9.63 — .39* .41** .29 .42**
2. Baseline scrupulosity (PIOS-R total score) 25.60 14.87 — .97** .88** .38*
3. Fear of sin (PIOS-R subscale) 19.10 10.56 — .74** .41**
4. Fear of God (PIOS-R subscale) 6.50 5.27 — .24
5. Baseline trauma-related mental contamination (PEMC) 49.90 14.61 —
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Note. *p < .05; **p < .01.

Results from daily monitoring

Participants completed a total of 948 out of 1,120 possible daily assessments, resulting in an overall response rate of 84.6%. The mean number of responses per participant was 23.70 (SD = 5.30, range 7-28). There was no systematic linear change in daily sexual trauma-related mental contamination (B = −0.002, SE = 0.005, t = −0.34, p = .740) or daily PTSD symptoms (B = −0.006, SE = 0.007, t = −0.93, p = .361) over the two-week monitoring period, controlling for weekday vs. weekend.

Consistent with hypotheses, baseline total scrupulosity predicted increased daily sexual trauma-related mental contamination (B = 0.19, SE = .07, t = 2.74, p = .010), controlling for baseline PTSD symptoms, between- and within-person daily PTSD symptoms, and baseline sexual trauma-related mental contamination. Neither fear of sin (B = 0.16, SE = .14, t = 1.17, p = .251) or fear of God (B = 0.24, SE = .25, t = 0.95, p = .351) uniquely predicted daily sexual trauma-related mental contamination when entered into the model at the same time.

Counter to hypotheses, baseline total scrupulosity was not a significant predictor of daily PTSD symptoms (B = −0.10, SE = .08, t = −1.31, p = .198), controlling for baseline PTSD symptoms, baseline sexual trauma-related mental contamination, and between- and within-person daily sexual trauma-related mental contamination. Similarly, neither fear of sin (B = −0.08, SE = .15, t = −0.55, p = .584) nor fear of God (B = −0.13, SE = .28, t = −0.47, p = .639) uniquely predicted daily PTSD symptoms when entered into the model at the same time.

Discussion

The current study presents a unique contribution to the literature by examining scrupulosity in a trauma-exposed sample as well as associations between scrupulosity, sexual trauma-related mental contamination, and PTSD symptom severity. Scrupulosity was significantly and positively associated with baseline sexual trauma-related mental contamination and baseline PTSD symptoms. Additionally, individuals who met criteria for PTSD endorsed significantly higher baseline sexual trauma-related mental contamination; however, scrupulosity scores did not significantly differ between those with and without PTSD. The lack of a significant difference in mean scrupulosity scores between those with and without PTSD, despite the fact that there was a significant correlation between PTSD symptoms and scrupulosity, is likely related to measurement differences. Specifically, the difference in continuous versus dichotomous measurement of PTSD, such that the dichotomous analysis did not allow for capturing nuanced differences in scrupulosity. Notably, the average symptom load for PTSD was relatively elevated in this sample, and participants without PTSD were not asymptomatic. As such, additional research is needed among individuals with a broader range of PTSD symptoms to provide more generalizable conclusions regarding scrupulosity differences among those with versus without PTSD.

As hypothesized, baseline scrupulosity prospectively predicted higher daily sexual trauma-related mental contamination while controlling for baseline PTSD symptoms, sexual trauma-related mental contamination, and daily PTSD symptoms. However, facets of scrupulosity (i.e., fear of sin and fear of God) did not uniquely predict daily sexual trauma-related mental contamination. Contrary to hypotheses, baseline scrupulosity did not significantly predict daily PTSD symptoms when controlling for baseline PTSD symptoms, baseline sexual trauma-related mental contamination, and daily sexual trauma-related mental contamination.

In the aftermath of sexual trauma, individuals with higher levels of scrupulosity may be more likely to experience sexual trauma-related mental contamination, including feelings of dirtiness or moral impurity. These experiences may trigger compulsive behaviors (e.g., washing, cleaning, praying) aimed at maintaining or recovering moral purity or avoidance of triggers, which can prevent corrective learning and may maintain or worsen sexual trauma-related mental contamination. It is also possible that individuals with higher levels of scrupulosity may be more likely than those low in scrupulosity to interpret posttraumatic intrusive memories or feelings of disgust as the current source of defilement, and may be more likely, in turn, to judge themselves as dirty or impure and respond with behaviors to alleviate dirtiness as a result. Future research may further explore the relation between scrupulosity and sexual trauma-related mental contamination to better determine clinical implications. It is worth noting that over 50% of this community-recruited sample scored at or above a clinical cut off for scrupulosity warranting potential treatment (Shapiro et al., 2013). Additionally, mean levels of scrupulosity were higher among the present sample than other nonclinical or community-recruited samples not assessed for trauma exposure (e.g., Fergus, 2014; Olatunji et al., 2007). This indicates the possibility that scrupulosity is a relevant concern for some individuals with sexual trauma histories and may be important for clinicians to assess at the start of treatment to help inform treatment targets. For example, scrupulosity-related beliefs (e.g., “I am afraid of having immoral thoughts”) may be important therapeutic targets if these beliefs lead to the development or maintenance of sexual trauma-related mental contamination, compulsive behaviors, and avoidance (e.g., of trauma reminders or religious/moral triggers). Clinicians may also consider assessing scrupulosity-related motives for experiential avoidance of trauma cues; for instance, assessing whether a patient avoids thoughts, memories, or feelings related to the trauma due to concerns about sin or immorality. Given research suggesting that mental contamination is indirectly associated with PTSD symptoms through trauma-related negative cognitions (Olatunji et al., 2008), it is particularly important to understand what negative cognitions may be linked to scrupulosity and/or mental contamination. Along this theme, recent work has focused on methods to improve the assessment and treatment of individuals with co-occurring OCD and PTSD (Pinciotti et al., 2022).

Regarding the facet level measures of scrupulosity, fear of God refers to fears based on an external judge of morality (e.g., worries about upsetting God or about heaven and hell), whereas fear of sin captures concerns related to an internal moral compass (e.g., worry about having dishonest, immoral, or sexual thoughts, or acting immorally). The significant correlation between baseline sexual trauma-related mental contamination and fear of sin, but not fear of God, suggests that sexual trauma-related mental contamination may be more related to an internal sense of morality than fear of judgement from an external deity. It is also worth noting that prior research in a nonclinical sample found a stronger association between sexual disgust and fear of sin (versus fear of God), and an experimental induction of disgust led to increases in fear of sin, but not fear of God (Stewart et al., 2020), further supporting a potential relevance of internal sense of morality in experiences of dirtiness. However, the differential relationship between sexual trauma-related mental contamination and the two facets of scrupulosity may not be large enough in magnitude to impact the prospective prediction of daily mental contamination. Additionally, given very large correlation between the facet-level measures of scrupulosity, null findings regarding their ability to predict sexual trauma-related mental contamination is likely due, in part, to collinearity between these subscales

Several possible explanations for the lack of significant associations between baseline scrupulosity and daily PTSD symptoms warrant consideration. While there was a positive correlation between baseline scrupulosity and baseline PTSD symptoms, the variability of daily symptom measures was greater, and therefore more difficult to predict. Daily PTSD symptoms were measured with the PCL-5, which is a self-report measure. While this measure is well validated, it is possible clinician-administered assessments, such as the CAPS-5 that was administered at baseline, may more accurately capture PTSD symptoms. Another possible limitation is that scrupulosity could influence some PTSD symptoms or domains more than others; thus, the predictive power of scrupulosity to predict a total PTSD score is lacking. For example, negative alterations in cognitions (e.g., endorsing strong negative beliefs about oneself, other people, or the world) and mood (e.g., feelings such as fear, horror, anger, guilt, or shame) may share greater associations with scrupulosity than other symptom domains, such as hyperarousal. Additionally, the covariates included in this analysis are robust predictors of daily PTSD symptoms, and it is possible that they accounted for too much variance in daily PTSD symptoms for baseline scrupulosity to add to the variance explained by the model.

While the present study benefits from multiple strengths in design (e.g., longitudinal design and gold standard clinician-rated baseline PTSD assessment), there are several limitations. Retrospective sexual trauma history, baseline scrupulosity, and PTSD symptom severity were measured at the same timepoint, which precludes any temporal assessment of how scrupulosity, trauma, and PTSD symptoms may influence one another. It is possible that previous traumatic experiences and subsequent posttraumatic symptoms inflate scrupulosity-related beliefs in some individuals, which then confers an increased risk for sexual trauma-related mental contamination following sexual assault. Future research employing experimental and longitudinal cohort designs should be conducted to better understand these potential relations. Additionally, the daily diary assessments were collected over a two-week period. A longer period of daily assessment would be more robust to confounds. While daily assessments were completed at a high rate (84.6%), it is possible that missed assessments occurred on days when individuals were experiencing more severe PTSD symptoms and thus engaging in avoidance. If this is the case, missing assessments may systematically reflect days during which participants experienced higher sexual trauma-related mental contamination or PTSD symptoms. It is also worth noting that multiple day assessments for PTSD symptoms may affect the relevance of some items (e.g., assessing difficulty falling or staying asleep or nightmares in afternoon assessments if participants have not slept). Researchers might consider how to better address this in future research. There is also a need for more research to better define cut off scores for the PEMC, particularly for use in clinical samples. The present study, as a secondary analysis, was also limited with a relatively small Level 2 sample size. Despite the limited sample size, confidence in findings is supported by the use of Restricted Maximum Likelihood Estimation, which results in better estimates of the variance components of multilevel models when sample sizes are small (Raudenbush & Bryk, 2002), and evidence from simulation studies that find Level 2 sample sizes as small as 30 may produce unbiased estimates of fixed effects coefficients and corresponding standard errors (Maas & Hox, 2005). Future research should build upon this work by replicating with larger samples sizes to increase confidence in findings. It is also notable that the current sample was not limited to specific religions or denominations, and religiosity, spirituality, purity culture beliefs, and secularism were not assessed or controlled for. Religious orientation of a given sample could substantially influence study findings, given the relatively non-secular and monotheistic nature of many PIOS-R questions.

Despite these limitations, the present study extends current knowledge about the relations between scrupulosity, sexual trauma-related mental contamination, and PTSD symptoms by examining these constructs prospectively, using daily measures, and within a sexual trauma-exposed sample. Considering the somewhat mixed results regarding the relations between scrupulosity and PTSD symptoms, further studies employing varying methodological designs and samples are warranted. Future research is also needed to examine the influence of moral emotions (e.g., shame and guilt) and cognitions surrounding self-blame on scrupulosity and sexual trauma-related mental contamination. Prior research has shown greater feelings of dirtiness and desire to wash among survivors of completed or attempted rape compared to survivors of other types of sexual assaults (Ishikawa et al., 2015). Thus, studies comparing types of sexual trauma (e.g., penetrative vs. non-penetrative assaults) may help to clarify relations between scrupulosity, sexual trauma-related mental contamination, and PTSD symptoms. Given that the present focused specifically on women exposed to sexual trauma, and some research suggests that men may report greater fears of sin and God compared to women (Stewart et al., 2020), additional work is needed to study gender differences in these associations. Additionally, past experiences with religion and spirituality, religious affiliation, and purity culture beliefs may influence relations between scrupulosity and sexual assault recovery. Evaluation of the role of religious trauma (e.g., abuse inflicted by a religious leader or justified by religious texts; Panchuk, 2018) in the interplay between scrupulosity and sexual trauma, and the subsequent development of sexual trauma-related mental contamination, is also warranted.

Acknowledgments

Writing of this manuscript was supported by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs. Dr. Brake received support to conduct this project from the Office for Policy Studies on Violence Against Women at the University of Kentucky. This research was also supported by grants from the National Center for Advancing Translational Sciences (UL1TR001998) and the National Institute on Drug Abuse (T32DA035200) of the National Institutes of Health (NIH). The funding agency had no role in study design, data collection or analysis, or preparation and submission of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, the Office for Policy Studies on Violence Against Women, or the Department of Veterans Affairs.

Footnotes

Conflict of interest statement. The authors declare that they have no conflicts of interest.

Statement of informed consent. Informed consent was obtained from all participants included in the study.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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