From the moment Maria Urban wakes up, she is obsessed with performing an intricate sequence of prayers.
When she finishes her prayers to God, Mary and the guardian angel, she recites three Hail Marys and an Our Father. Then she kisses some pictures and crucifixes in her room, crosses her dog, reads Bible quotations, and crosses herself, dipping into a bottle of holy water she keeps by the kitchen sink. When she gets in her car to go to work, sometimes she'll start the prayers all over again.
"There could be some days where I may say 75 prayers," says Urban, who lives in Danbury, Conn., "and there could be some days I'd say like 175 prayers."
"I'm so frightened of hell I cannot enjoy my life right now," says Urban, who often calls every church in town just to speak with numerous priests so she can be assured she's keeping the devil at bay. "The thought of going to hell unfortunately doesn't leave my mind."
While the prayers and rituals come from Urban's Roman Catholic upbringing, the compulsiveness is all her own. Her urges are so uncontrollable that she has become an expert at hiding her rituals. For example, she kisses her crucifix when co-workers aren't looking and to cross herself, she pretends she's just scratching her forehead.
For more than a decade, Urban did not know what was wrong with her. She was misdiagnosed time and again, including four times that she was hospitalized for depression. Then, this past summer, despite years of taking antidepressants, Urban says things got worse.
"It got way out of control," she says. "It probably was up to 500 prayers a day."
Finally, she found therapist Christina Taylor, who specializes in Obsessive Compulsive Disorder (OCD), a brain disorder that affects nearly 6.5 million Americans. Urban was diagnosed with Religious OCD, also called Scrupulosity, a variation that experts say affects up to 10 percent of all OCD patients.
While many religions require complicated daily rituals that are designed to bring spiritual fulfillment, OCD patients like Urban never feel fulfilled, and so their rituals never end.
"It's not the religion per se that caused it," says Taylor. "It's just the context in which their particular symptoms unfold."
Taylor says that anyone who is vulnerable to OCD may develop Scrupulosity, but believers in religions that stress a punitive concept of God are more prone to it.
Religious Sacrifice Taken Too Far
Because a commitment to religious rituals can seem normal, many who suffer from this type of OCD do not get proper treatment.
Levi Marchetti's disorder, for example, almost cost him his life.
"I would read many times of the great sacrifices made by … Biblical figures," he says, so he, too, would deprive himself by not eating dinner. "I was willing to go through that uncomfort just to please God."
By the time Marchetti's parents took their son to the hospital, months of constant prayer and religious sacrifice had brought him to the point where he wasn't eating or speaking.
It was the most severe case of religious OCD that psychiatrist Thomas Cobb had ever seen.
Treatment, says Cobb, doesn't mean turning away from religion, but discovering a new way to make it a healthy part of life.
"The fact that it took him two hours in the morning to get dressed, because in his mind it was a matter of whether God wanted him to wear this shirt or that shirt was getting in the way of his finding comfort in his religious faith," says Cobb.
Urban's treatment involved exposure therapy, which put her face to face with her worst fears.
"If you're worried about the thought, then we want you to think about it more," explains Taylor. "That actually diminishes both the frequency of the thought and the anxiety about the thought."
Marchetti was treated with antidepressants and therapy.
"I haven't given up my religion," he says. "Religion is still very much a part of my life — but in a context where it's very normal."
Urban is still on the road to recovery, learning to attend Mass, for example, without engaging in excessive ritualizing.
"I want to be able to live and not think about this 24 hours a day," she says. "I don't think God wants me to be out there … depressed and miserable. I think he wants me to live a good life."