When a spiritual search turns into a compulsion

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, he was racked by fears of spiritual unworthiness, to the point of contemplating suicide.

Were he alive now, Loyola might 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. 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,” Ciarrocchi says, “and to all outward appearances, they’re functioning.”

St. Ignatius repeatedly attended confession, repenting the same sins over and over. (Martin Luther, likewise presumed to have had scrupulosity, did the same thing to try to 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 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% to 3% of Americans wrestle with obsessive-compulsive disorder, 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 obsessive-compulsive disorder exhibit symptoms such as continual hand-washing, hoarding, and constant checking of doors, locks and appliances. These behaviors have been given exposure in the TV show “Monk,” about a detective with the condition, and movies such as “The Aviator,” based on the life and compulsions of billionaire Howard Hughes.

For a smaller minority, however, the disorder manifests itself as scrupulosity, body dysmorphic disorder (preoccupation with one’s physical appearance), olfactory reference syndrome (body odor paranoia) or 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 obsessive-compulsive 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, Md. The center has treated thousands of obsessive-compulsive patients, and Mansueto 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,” he says, “and one false move, it’s curtains.”

He recalls an Orthodox Jewish teenager who made so many promises to God -- to drink only so many sodas a day, to visit 7-Eleven only so many times a week, to never switch radio stations midsong -- that keeping track of them got logistically impossible. It became debilitating.

“He couldn’t move,” Mansueto says. “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.”

People with this type of disorder are among the least-likely obsessive-compulsive sufferers to get treatment. It’s often difficult for them, as well as friends and relatives, to know where the line is separating extreme piety from obsessive ritual.

In addition, the disorder still carries a social stigma. Some patients undergo therapy for years before they feel comfortable revealing their secrets regarding the condition, according to Dr. Gerald Nestadt, professor of psychiatry at the Johns Hopkins School of Medicine.

“Without question,” Nestadt says, “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 9th or 10th century as an identifiable -- although at the time unnamed -- condition. Loyola’s Ciarrocchi notes this is when the Catholic Church instituted confessions. Priests, as a result, had occasion to come into contact with hyper-confessors.

Nowadays, Ciarrocchi says, scrupulosity is commonly encountered in adolescents who are in the process of developing moral and religious values, and in adult converts newly infused with spiritual beliefs.

A 28-year-old firefighter in the Washington area falls into the latter category. The man, who requested anonymity, was raised a non-practicing Jew, but became a Christian about 10 years ago while serving in the Air Force.

The first five months of his new life were blissful. Then he became increasingly scrupulous. He would retreat into his room for hours at a time, memorizing about 300 Bible verses word for word. 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,” his wife says.

“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 impulses through graduated, controlled exposure.

“You want to accept the intrusive thought,” Ciarrocchi says, “but reject the compulsion.”

Treatment has about a 60% success rate, experts say. That doesn’t mean obsessive-compulsives will be cured. But they can gain control of their illness.

“It’s important to teach them strategy,” Ciarrocchi says. “You’re only going to be in therapy a limited time, but OCD is for life.”

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Understanding scrupulosity

Obsessive-compulsive disorder is estimated to occur in 1% to 3% of the population, about the same incidence as schizophrenia. Scrupulosity is a form of obsessive-compulsive disorder in which people become preoccupied with religious and moral behavior, often lapsing into eccentric rituals.

For more information, consult these sources:

* Obsessive-Compulsive Foundation: (203) 401-2070 or www.ocfoundation.org.

* Anxiety Disorders Assn. of America: (240) 485-1001 or www.adaa.org.

* The Scrupe Group, a self-help Web community devoted to scrupulosity: groups.yahoo.com/group/the_scrupe_group.