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OCD, Religion and Scrupulosity

    ASDI also treats sufferers of OCD and scrupulosity.

    OCD Sufferers Consumed by Religion

    By Tom Dunkel
    The Baltimore Sun
    September 9, 2005

    "Show me, Lord, where I can obtain help: and if I have to follow a little dog to obtain the cure I need, I am ready to do just that." A troubled Inigo de Loyola - founder of the Jesuit order, a man whose unquestionably pure heart eventually earned him canonization as St. Ignatius Loyola - wrote those words more than 450 years ago. Surprisingly, Loyola was racked by fears of spiritual unworthiness, to the point of contemplating suicide.

    Were he alive now, he may be diagnosed as having "scrupulosity," a little-known, narrowly targeted obsessive-compulsive disorder in which individuals are consumed by religious and moral fervor. Today, however, Loyola wouldn't have to search far for help. In fact, he could find it at the institution that bears his name. Joseph Ciarrocchi, a priest turned clinical psychologist, is head of the Pastoral Counseling Department at Loyola College in Maryland's Columbia graduate center. He's also author of The Doubting Disease, published in 1995 and widely regarded as the first practical guide to scrupulosity. "It's unbelievable what people suffer in private," says Ciarrocchi, "and to all outward appearances they're functioning."

    St. Ignatius repeatedly attended confession, repenting the same minor sins over and over. (Coincidentally, Martin Luther, likewise presumed to have had scrupulosity, did the same thing to try and soothe his perpetually uneasy conscience.) Ciarrocchi has had patients who spend as much as 12 hours a day praying. He says he once treated a Third World-based priest who, after conducting his weekly outdoor Mass, would crawl on the ground searching for imaginary slivers of Communion wafer. In his mind a priest had to be perfectly fastidious about discharging his holy responsibilities or else risk the wrath of God.

    An estimated 1 percent to 3 percent of Americans wrestle with obsessive-compulsive disorder (OCD), according to the National Institute of Mental Health. Abnormalities in the brain's production of the chemical serotonin are known factors. Genetic and environmental causes also are suspected to come into play. Most people with OCD exhibit symptoms such as continual hand-washing, hoarding and constant checking of doors, locks and appliances. These behaviors have been given popular exposure in the TV show Monk, about a detective with OCD, and movies like The Aviator, based on the life and compulsions of billionaire Howard Hughes.

    For a smaller minority, however, OCD manifests itself as scrupulosity, "body dysmorphic disorder" (the preoccupation with one's physical appearance), "olfactory reference syndrome" (body odor paranoia) or other less common phobias. "Like all OCD behaviors there's a spectrum of severity," says Bruce Hyman, a psychotherapist in Hollywood, Fla., and co-author of The OCD Workbook: Your Guide to Breaking Free From Obsessive-Compulsive Disorder. Hyman considers scrupulosity to be one of six basic OCD types, but adds that it's comparatively rare. "I may get two cases a year," he says. "For a guy who sees almost exclusively patients with OCD, that's a very small number."

    Charles Mansueto is director of the Behavior Therapy Center of Greater Washington in Silver Spring. The center has treated thousands of OCD patients, and he estimates that about one in 50 are cases in which scrupulosity is the dominant symptom. "Many people who are scrupulous have a notion that they're being watched," Mansueto explains, "and one false move, it's curtains." He recalls a teenage boy who was an ultraobservant Orthodox Jew. He made so many promises to God - to drink only this many sodas a day, to visit the neighborhood 7-Eleven only so many times a week, to never switch radio stations in midsong - that keeping track of them got so logistically impossible it became debilitating. "He got paralyzed. He couldn't move," says Mansueto. "He literally couldn't get out of his chair." A few years of psychotherapy helped. So did a mock cleansing ritual Mansueto arranged with the boy's rabbi that absolved him of having to adhere to all those tangled promises. "I went to that young man's wedding and know his children," Mansueto adds. "He's light years away from where he was when he was in the depths."

    Scrupulous people are among the least likely OCD sufferers to get treatment. It's often difficult for them, as well as friends and relatives, to determine where the line is that separates extreme piety from obsessive ritual. In addition, there's still a social stigma attached to OCD. Some patients undergo therapy for years before they feel comfortable revealing their obsessive-compulsive secrets, according to Dr. Gerald Nestadt, professor of psychiatry at the Johns Hopkins School of Medicine. "Without question," says Nestadt, "people will tell you about their sex lives or criminal behavior before they'll tell you about their OCD symptoms."

    Scrupulosity probably dates to the ninth or 10th century as an identifiable - although at the time unnamed - condition. Loyola's Ciarrocchi notes this is when the Catholic Church instituted confessions, and priests, consequently, had occasion to come into regular contact with hyper-confessors. Nowadays, says Ciarrocchi, scrupulosity is commonly encountered in adolescents who are in the process of developing moral and religious values, and in adult converts newly infused with a holy spirit.

    A 28-year-old firefighter in the Washington area who requested anonymity falls into the latter category. He was raised a nonpracticing Jew, but became a Christian about 10 years ago while serving in the Air Force. The first five months of his born-anew life were blissful. Then he became increasingly scrupulous. He would retreat into his room for hours at a time, committing to word-for-word memory about 300 Bible verses. He'd dissect church sermons and agonize over his prospects of salvation. "'Do you really think I'm saved?' He'd probably ask me that 10 times a day," says his wife. "I'd get frustrated. I felt like a broken record answering his questions." "It became a huge tormenting thing for me," he says. "I started fearing I was never converted or saved. I would have blasphemous thoughts, cursing God in my mind. I'd have to pray to get rid of it." A pastor recommended counseling, and after two years it is working. "Even though it's still a struggle for me, now I realize it's a disease," he says.

    The standard modes of intervention are medication - antidepressants such as Zoloft and Paxil are often prescribed - and cognitive-behavior therapy, in which patients learn to manage their particular rituals and impulses through graduated, controlled exposure. "You want to accept the intrusive thought," says Ciarrocchi, "but reject the compulsion." Treatment has about a 60 percent success rate, experts say. That doesn't mean obsessive-compulsives will be cured. They can, however, gain control of their illness. "It's important to teach them strategy," adds Ciarrocchi. "You're only going to be in therapy a limited time, but OCD is for life."

    Obsessive-compulsive disorder ranks as the fourth-most-common psychiatric diagnosis, according to Bruce Hyman, a Florida psychotherapist and co-author of The OCD Workbook: Your Guide to Breaking Free From Obsessive-Compulsive Disorder (New Harbinger Publications). OCD is estimated to occur in 1 percent to 3 percent of the population, about the same incidence as schizophrenia and diabetes. Scrupulosity is the form of OCD in which people become preoccupied with religious and moral behavior, often lapsing into eccentric rituals.

    For more information, consult these sources: The Obsessive-Compulsive Foundation: 203-401-2070; Anxiety Disorders Association of America: 240-485-1001; is Bruce Hyman's OCD-related Web site. The Scrupe Group is a self-help Web community devoted to scrupulosity:

    The Doubting Disease: Help for Scrupulosity and Religious Compulsions
    by Joseph W. Ciarrocchi

    ASDI: Serving the Baltimore Area & Central Maryland