Chad's bout with scrupulosity began earnestly enough.
An Idaho health-care worker and devout Mormon, Chad (who asked that his real name not be used) began wondering if he was totally upfront with patients. Soon, he started scrutinizing his past, looking for times he might not have been completely honest.
"It started to steamroll on me," the 35-year-old man says.
He began phoning and e-mailing past bosses and acquaintances. Did he deliver every paper on the route? What about that Snickers bar he snatched from the discard bin as a teenage bag boy? Or the sod that fell off the landscaping truck he was driving? Or the loaned scrubs he kept in college?
"It included me sending checks to people," Chad recalls. "I sent the same people the same check over and over again, worried it wasn't enough."
Eventually, he began obsessing about his honesty in every new and future encounter. When he finally told his wife he might have to leave The Church of Jesus Christ of Latter-day Saints because every time he went to church he thought of some new evidence of his own dishonesty, it scared her. "She recognized I had a problem and said, 'Let's get help.' "
A year later, Chad now knows he suffers from scrupulosity, an obsessive compulsive disorder (OCD) in which worries of religious or moral nature consume an individual. The term derives from the Latin word for a small stone, such as an irritating pebble in one's shoe.
The doubting disease
Though it has been described for centuries in Catholic literature and afflicted saints such as Ignatius of Loyola, Alphonsus Liguori and Catherine of Siena, as well as reformer Martin Luther, scrupulosity has been recognized in the field of psychology only in recent decades.
A series of books, beginning with The Doubting Disease: Help for Scrupulosity and Religious Compulsions in the mid-1990s, helped raise awareness.
Scrupulosity is not in itself a diagnosis, but falls within the OCD family of anxiety disorders, explains Jonathan S. Abramowitz, a clinical psychologist and researcher in the field at University of North Carolina in Chapel Hill.
Unlike the normal person who can reject intrusive thoughts and everyone has them people with OCD get tied in knots by their mistaken ways of thinking and behaving, Abramowitz says. They cannot handle ambiguity, which makes it hard for one who is scrupulous to remain a person of faith.
Chad recalls an anguishing moment when his need for certainty peaked: He told his therapist he wanted God to assure him in person that he is OK or he wanted to know there is no God.
According to the International OCD Foundation, up to 3 million U.S. adults and about 500,000 children suffer from OCD. Of those, 5 percent to 30 percent have scrupulosity, according to one estimate.
Its sources are biological and likely environmental, but Abramowitz believes OCD manifests itself as scrupulosity mostly in those who care a lot about their faith, whether that is Christianity, Judaism, Islam, Buddhism or Hinduism. Conversely, it makes it difficult for the faithful to remain faithful.
A Catholic woman may confess to her priest constantly about intrusive obscene thoughts while gazing on a crucifix, a "sin" she fears is unforgivable, while an Orthodox Jew might worry obsessively that he didn't keep his milk separate from his meat in accord with kosher law.
"Folks with scrupulosity have a pretty harsh view of God. They see him as looking down with a magnifying glass, waiting for people to screw up so he can blast them with lightning," Abramowitz says. "That runs counter to what most religions teach."
Virtuous or vexing?
One problem in identifying scrupulosity is that it can look like virtue, says John Dehlin, a doctoral student in psychology at Utah State University who is researching a new treatment.
For instance, scrupulous Mormons may spend hours every day reading scripture or praying.
"It's easily dismissed as virtuous," Dehlin says, "and held up as a beautiful thing."
But what might be a sign of sanctity in a normal person is all about relieving anxiety in the one who is scrupulous.
While scrupulous Latter-day-Saints struggle with the same issues others do like intrusive, vulgar thoughts in church Dehlin says he has found obsessions over sexuality and masturbation to be particularly common among young Mormons afflicted with scrupulosity. Fear of being dishonest often crops up as well.
A Mormon man who wanted to apologize to a graduate-school search committee a decade after sending in a rÃ©sumÃ© with a minor error was telling himself, " 'If I don't do this, then Christ's atonement will not apply to me and I will be a son of perdition,' " Dehlin recounts.
He uses a "perfect storm" analogy to answer why scrupulosity strikes some and not others: If a person is prone to OCD and raised in a strict, orthodox home with religious teachings that include high stakes on Earth as well as the hereafter he or she may be susceptible.
Dehlin says a missionary who sets his alarm at 3 a.m. to interrupt any "sinful" wet dreams may be obsessing about his ability to complete his mission, marry and reach heaven.
"You can't blame the parents, the person, the church, the religion," he says. But, he adds, "you don't hear about scrupulosity among Unitarian Universalists," a faith that offers believers wide latitude.
Mild to serious
Natasha Parker, a marriage and family therapist in Wichita, Kan., who blogs at mormontherapist.blogspot.com, says she sees much more "inappropriate guilt and shame" than scrupulosity among LDS clients, although both tend to focus on one part of the church's message that members should strive for perfection.
Those in the grips of scrupulosity, she says, tend not to think about Christ's mercy and atonement.
"To say someone has scrupulosity doesn't tell you much," says William Van Ornum, author of the 1997 book A Thousand Frightening Fantasies: Understanding and Healing Scrupulosity and Obsessive Compulsive Disorder.
That's because scrupulosity ranges from mild to debilitating, says Van Ornum, a psychology professor at Marist College in Poughkeepsie, N.Y. He also writes online for America Magazine, a Jesuit publication.
While researching his book, he sent a four-page survey to 10,000 members of Scrupulous Anonymous, most of them Catholics who subscribe to Liguori Publications' newsletter on scrupulosity. (St. Alphonsus Liguori was an 18th-century Catholic bishop who suffered from the disorder.) More than 1,000 surveys were returned.
Those with the mildest form of scrupulosity actually may find it a help to their integrity, Van Ornum says. For instance, one doctor reported going home at night and mentally reviewing every patient's case before he could eat dinner. That way, he would allay his obsession that he had missed something.
But in its most serious forms, Van Ornum says, scrupulosity can leave a person disabled and depressed.
The professor says he was struck, too, by the parallels between today's treatments and those prescribed centuries ago by Catholic thinkers such as Jesuit founder St. Ignatius, who once obsessed about stepping on twigs that were arrayed like a cross.
St. Ignatius wrote in the 16th century that the sufferer should "always go against the scruples," an approach that mirrors today's cognitive-behavior therapy. And Ignatius wrote in his Spiritual Exercises about substituting loving images of God for worries of giving offense.
"He knew what it was like," Van Ornum says, "and it tortured him."
How it's treated
Scrupulosity is treated essentially the same way as other types of OCD, with a combination of medication and cognitive-behavior therapy.
But finding therapists who are sensitive to faith can be hard, Van Ornum says. "It has to be someone who understands and who doesn't give off silent contempt or silent disapproval."
Abramowitz says treating scrupulosity can be difficult because patients may view the remedies as undermining their faith.
Therapists use what is called exposure and response (or ritual) prevention. For instance, if a therapist is trying to help a man whose obsession is the intrusive thought "f-God," she might "expose" him to the unwelcome words by requiring he say them out loud.
"It's difficult because â¦ what worse thing could you hold over somebody's head than their eternal salvation?" says Lori Riddle-Walker, a family and marriage therapist in Escondido, Calif., who has patients with scrupulosity.
She says it often helps to have patients sort out the difference between their true beliefs and their obsessions, and that can mean consulting a religious leader.
"With people willing to work, I've usually been able to find exposures that are within their value systems," says Riddle-Walker, who has a bachelor's degree in theology. Even so, she says, "I've had people drop out of therapy because they couldn't take it."
'Can't fix everything'
Dehlin, at USU, says the new kind of therapy he is researching does not require the problematic exposure, although it remains in the cognitive-behavior tradition.
So far, it is promising, says Dehlin, who hopes more patients will come forward to participate in the study.
Chad, the Idaho man obsessed with honesty, has been through the USU therapy and credits it, as well as medication, with helping him control his compulsion to make amends for perceived mistakes.
"It's still a fight for me," he says. "I have to be very cognizant and on alert that I don't let myself go down that track."
And though scrupulosity almost cost him his religion, it now is helping him develop greater faith.
"I've come to accept I can't go back and pay all those quarters back. I'm realizing I can't fix everything. I have to rely on the atonement."
What is "scrupulosity"?
Scrupulosity is a form of obsessive compulsive disorder (OCD) involving religious or moral obsessions. Scrupulous individuals are overly concerned that something they thought or did might be a sin or other violation of religious or moral doctrine.
Source: International OCD Foundation
Utah State University's psychology department is researching the effectiveness of psychological treatment for scrupulosity or unwanted, disturbing and uncontrollable thoughts or behaviors of a moral or religious nature. Study participants are not compensated, but receive 15 hours of treatment free. Those interested should contact John Dehlin and the research lab at 435-535-1073 or e-mail firstname.lastname@example.org.
Information about the USU research lab can be found at twohig.usu.edu/htm/current-studies.
More on the Web
O The International OCD Foundation: http://www.ocfoundation.org
• Scrupulous Anonymous: mission.liguori.org/newsletters/scrupanon.htm