Wednesday, September 10, 1997
10 am. Telephone Call with Ms. Schultz regarding Rachel Tanner. Ms. Schultz (I never asked her first name--she sounded so grandmotherly), called to enlist my assistance with her granddaughter Rachel, for whom she cares. Rachel is about 21 and is employed as a manicurist. She seems to be suffering from obsessive compulsive disorder, manifested in a series of behaviors particularly focused on grooming. Ms. Schultz told me that she was obsessive about her hair, nails, and that she took excessively long showers. I'm not certain to what extent Rachel's obsessive rituals dimish her functioning, but I've seen patients in the past who were completely paralyzed by their need to complete complex and time-consuming rituals. The grandmother was calling without her granddaughter's knowledge, so I'm not certain whether this initial contact will actually produce a patient. Rachel may or may not recognize that she has a problem. The grandmother told me that Rachel was a good student who dropped out of school at the time of her mother's death, when she was about 18 years old. She has an older brother who apparently has left the grandmother's home. We made an appointment for Rachel for a week from this coming Tuesday.

Tuesday, September 23, 1997
1 pm. First Session with Rachel Tanner. Rachel is 21 years old. She's slightly overweight but attractive. She seems to dress a bit young for her age--she had a stripped shirt and baggy pants. She had deep circles under her eyes--I assume that's from lack of sleep. Rachel was constantly using her left hand to scoop her long henna brown hair over her left ear. Her hair was probably once extremely attractive, but it's now clearly thinning as her grandmother described. I could see that she was trying to cover up some of the thinning problems by using her bangs and a barrette. I've seen that type of hair loss in several of my OCD patients in New York. Usually, it's the result of obsessive over-brushing. My suspicions were confirmed by Rachel during the session. Rachel counts things--she counts the number of brush strokes. But she can't stop until she does a set number of strokes. If she's interrupted or miscounts, she has to start brushing all over again. The hair loss is a result. I also noticed that she constantly picks her nails--first, she pushes the cuticles of one hand with the fingernails of the other, and then she cleans her nails by digging the nail of one finger under a nail on the opposite hand. She always starts with her thumb, then moves on to the middle, and so on until she's finished with that hand. If I'd asked her to stop, I'm pretty sure she would not have been able to. And yet Rachel is very self conscious. When she first came in, she had trouble relaxing enough to sit down. Rachel told me that she was worried that I just wouldn't understand her and label her crazy. She said that she believed that her grandmother probably thinks that she is crazy, and that's why she'd contacted me to try and help her granddaughter. Rachel described an incident when she was unable to leave the shower for three hours. She has a certain order to washing her body, and if she makes a mistake she would have to start from the beginning. The problem is that the order changes from week to week and Rachel just couldn't remember how do it right. After some time, her grandmother got scared and started to pound on the bathroom door. Now, she times Rachel's showers and after ten minutes shuts off the water. Halfway through our session, I mentioned Obsessive-Compulsive Disorder or OCD. I just wanted to know if she ever heard of it. But Rachel jumped at this diagnosis right away. It was clear that she needed something to help her understand her own behavior and the constant need to do things. She even went as far as diagnose her own mother with the same affliction. Rachel's mother died three years ago in a car accident. Rachel believes that it might have been a suicide--the day of the accident she didn't follow her standard routine. I asked Rachel to describe some of her mother's obsessions. Apparently, Rachel's mother had to check things--the doors, the stove, the lights, etc. Her obsessions mainly involved safety issues. But Rachel's obsessions are different, and she recognizes that. Rachel's are mostly about personal hygiene. She said that she first started experiencing these symptoms after her mother's death. She describes her rituals as "being good." They are the retribution for being "bad" when her mother was alive. But being bad, as Rachel describes it, was really just a child's way of coping with living with an OCD mother. Rachel talked about not dusting well and not really cleaning her room right--things that most kids do anyway. But now, Rachel feels that she has to pay for those childish misdeeds. She punishes herself for her mother's death even though she understands that it's not a logical thing to do. When she discussed her mother's death, she began to cry, but was able to stop, although her face plainly reflected her sadness and grief which were mixed with her fatigue. Rachel does have typical symptoms of OCD, but I am hesitant to begin a somatic treatment until I have a chance to get to know her better.

Tuesday, October 7, 1997
1 pm. Second Session with Rachel Tanner. Rachel came in with a misshapen scab on her nose about an inch long. She explained that she had compulsively and repeatedly scraped her face until she broke the skin. She said that this wasn't the first time. She still looked like she wasn't getting enough sleep, although she didn't appear disheveled. Rather, it was the dark circles under her eyes. Her cuticles are still obviously red and swollen. I believe that, in addition to OCD, Rachel is suffering from clinical depression probably triggered by her mother's death. I began a suicide assessment, and Rachel indicated that she had suicidal ideation but no present intent. I was concerned that Rachel might have found our last session disturbing, and she confirmed that she hadn't scraped her face in a long time and that she was having some difficulty sleeping, but she also said that she wasn't counting as much. While I'd like to take the credit, I haven't done anything yet which would have reduced her counting. I did try some basic relaxation exercises during this session in an attempt to allow Rachel to see that she could conquer some aspects of her OCD if she desired. I have to give Rachel a feeling of being in control. I believe that Rachel's obsessions are a manifestation of a woman trying to gain control over a world where she had lost so much. She couldn't control the events leading to her mother's death, but she is able to gain some control through rituals. I want her to see that she can gain that control in other ways. So I asked her to concentrate on just keeping her hands still, and she was able to with some application of effort on her part. She told me about a panic attack brought on by some birds bathing in a swimming pool in which she was about to swim. Rachel has a fear of contamination--the thought of bird lice and the floating feather that the birds left on the water was just too much for her. Rachel obviously knows that she has a problem and is beginning to see that she is losing function because of it. But I think that Rachel is willing to work quite hard in therapy. When I talked about the loss of freedom that the OCD has occasioned and how she must feel trapped by the disease, she broke down and cried. I guess I panicked a bit, because I gave her the tissues and impulsively gave her the sheep which Christina had brought me back from England. Rachel seemed to genuinely like the sheep--it seemed to make her feel a bit better--so perhaps I found it a good home after all. I hope that Christina won't comment on its absence.

Tuesday, October 21, 1997
1 pm. Third Session with Rachel Tanner. Rachel lost her job doing nails in a salon, perhaps as a result of her OCD. Rachel believes that her thinning hair made the salon owner feel that Rachel was not projecting the right image to her customers. I suspect that it might go far beyond that and that Rachel's compulsions are interfering with her ability to function. I'm quite fond of Rachel and I would like to be able to free her from the confines of her disease. She's obviously very bright and she's trapped beneath the burdens imposed upon her by her rituals. She told me that she feels that if she doesn't take a number of steps which is a multiple of five, that she can cause some harm to come to her brother Michael. I know that I'm not going to have any particular success in trying to stop the ritual itself, but I thought that I might be able to disassociate the ritual from the guilt. So I had Rachel record a superstitious statement that sounded silly even to Rachel as she said it, and asked her to play the tape several times daily--I'm hoping that intellectually she'll find herself rejecting the statement with more and more fervor even though emotionally she'll still feel as if it has validity. The fact that she is losing ability to function because of her compulsions gives a certain impetus to my decision to begin a somatic trial lasting at least 8 weeks on either clomipramine or a serotonin reuptake inhibitor. I think the likelihood of the best short term result is with clomipramine, but I'm concerned about the sedative potency of the tertiary amines. Therefore, I'm leaning towards fluoxetine. I'm going to prescribe 20 mg. of Prozac, once each morning. Warn Rachel to report any transient nausea, vomiting, insomnia, and agitation or nervousness. I've never talked with Rachel about her sex life, but fluoxetine poses a potential for sexual dysfunction including anorgasmia, although rare at the low doses with which I'm starting. I must caution Rachel to have realistic expectations for somatic treatment. Even after a successful trial, most patients with OCD still have substantial symptoms. And a full response to the medication can take months. In the sessions to come, I'd like to concentrate on understanding Rachel outside of the effect of her OCD, and I'd also like to try to understand the psychological underpinnings that led Rachel to escape into the comforting predictability of her rituals. I think it is clearly related to her mother's death, but it also seems possible that some of the answer is locked up in her experience with school. She was a good student until her mother's death, and thereafter, she shunned education. When I suggested that she might consider going back to school now that she is unemployed, she had a strong negative emotion reaction--dismissing the suggestion out of hand in a way atypical of her usual anxiousness to please. I allowed her to abruptly change the subject, but we'll have to return to it and discover the reasons that make the subject so charged with emotion.

Tuesday, November 4, 1997
3 pm. Fourth Session with Rachel Tanner. Rachel's fidgeting might have decreased, but her hair thinning continues and she now looks as if she has been plucking her eyebrows. But overall, we may have made some small headway in the counting rituals. She played the tape we made last session 20 times in the first three days and was able to replace one ritual for another--but only after checking with Michael and making sure that he hadn't been harmed by the substitution. Rachel's grandmother heard the tape and it precipitated a frank discussion about Rachel's problems. Rachel's grandmother revealed, in some detail, the OCD difficulties that Rachel's mother had--including particular phobias against contamination. I think that Rachel believes that we are making progress in the sessions, and I tried to reinforce that belief by summarizing the positive results we've already achieved. Rachel is willing to try a somatic treatment, so I prescribed 20 mg. of Fluoxetine, once each morning, as the beginning of an eight week trial, and I warned her of possible side effects.

Tuesday, November 18, 1997
3 pm. Fifth Session with Rachel Tanner. I was pressing Rachel on her apprehensions about going back to school when she fled from my office. She clearly has some strong issues regarding school that she is presently unwilling to discuss. Earlier in the session, she briefly showed me a notebook she had been writing in. Some of what she wrote questioned the logic of her assumption of responsibility for incidents affecting her brother Michael. For example, Michael said that he got a staff infection and Rachel started questioning whether it was because of something she had failed to do. Then, in the notebook, she questioned whether what she did made any difference to things that happen to her brother sixty miles away. I talked about OCD being a "doubting disease" in that the brain causes obsession over some thought or action. I remember a patient who would check to make sure that she had locked the front door ten, fifteen, sometimes twenty times, going back to check each time. I suggested that Rachel use a timer to delay performing a ritual for a set period of 15 minutes. Rachel has been on the Fluoxetine trial for 10 days now. She reports a feeling of heightened sensation, an increase in the swallow reflex, and an increase in her energy level. None of the sensations that she ascribes to the drug, however, are disturbing to her.

Wednesday, November 26, 1997
3:40 pm. Telephone Conversation with Ms. Anna Schultz respecting Rachel Tanner. Ms. Schultz called and sought some information about Rachel Tanner, her granddaughter. Of course I demurred, citing professional confidences. Ms. Schultz seemed to understand and went on to tell me about Rachel's mother and her dysfunctional sexual relationship with Rachel's father, Wolfgang. Anna described him obliquely as "demanding." Anna also seemed concerned that she might have told Rachel too much. I had an odd impression of Anna, actually, that she might be more reticent in giving Rachel information about her mother and her family than I had believed. I'd understood that Rachel found it difficult to talk openly with her grandmother, but Anna seems to be of the old school of repressive social interaction. Although it was painful for Anna to tell me, she finally revealed that Rachel has either plucked or shaved all of her pubic hair. I suspect that she plucked it, which sounds somewhat excruciating. But Anna believes that Rachel has gotten better since beginning therapy--she sees a lot of positive signs in her behavior. I told Anna that I would keep her call, and the information that she had provided to me, confidential and asked her to do the same.

Tuesday, December 9, 1997
3 pm. Sixth Session with Rachel Tanner. Rachel revealed a little of the reasons which make the prospect of returning to school so unpleasant. About two years ago, before her mother died, she planned to lose her virginity with a boy she met at junior college. Rachel describes changing her mind in the middle of the act. Apparently, she communicated her change of heart to the boy, but he continued regardless. The encounter was probably a rape and Rachel fears that she may see the boy again--although she admits that the chances of that are fairly slim. I feel unsatisfied by this explanation of why she has an almost phobic reaction to the concept of returning to school. I think that it is probably much deeper than what she described and I think it likely involves the death of her mother. It's possible that it involves some break in ritual or routine which Rachel believes was responsible for her mother's death in some manner--an explanation which she won't present to me because she knows that I'll dismiss her rationale. Sometimes these magical modes of thinking have an importance to the OCD patient, even if they make them believe they are responsible for some trauma, like the death of a parent, when they are clearly free from fault. It's as if, by taking the blame onto themselves, they give some reason for a random event--the guilt is better than the chaos. Rachel believes that her father repeatedly raped her mother. She remembers parental disputes which frequently left her mother in tears. Rachel blames her father for "ruining" her mother--she was clearly still very angry with him. He left when she was almost twelve. Rachel seems to be reacting well to the Fluoxetine, so I'm continuing the trial. She reports her rituals as subsiding somewhat, although she has described some difficulty in achieving orgasm, which although she has been able to overcome it, she ascribes to the Fluoxetine. Rachel is going to stay with her brother for a few days which I think is quite positive. I've seen OCD patients who were quite paralyzed and couldn't think of leaving familiar surroundings--after all, how'd they do their rituals? She's clearly looking forward to it--he's promised her a concert and an interesting roommate.

Tuesday, January 6, 1998
3 pm. Seventh Session with Rachel Tanner. Rachel is evidencing substantial improvement which I ascribe primarily to the fluoxetine trial. She described a visit to her brother's apartment where she was able to adjust quickly to an unfamiliar environment. She told me that she stopped the rituals--a conscious decision that they weren't going to do any good. She told me that the inner voice that used to be mercilessly critical has moderated its tone so that the voice has congratulatory elements. Rachel told me that she had a crush on her brother's roommate Evan, and she adapted quite readily to their lifestyle. She described one embarrassing moment where she was in the bathtub practicing her aquatic masturbation technique when Evan walked in--but the incident was passed over. Rachel told me that she's interested in going back to school--in fact, she's going to register for the upcoming semester. Because she's late, she'll have difficulty getting into the classes that she desires, but she seems reconciled to that--going back to school has suddenly become important to Rachel. I'm somewhat surprised, given her previous vehemence against it, but I'm certainly pleased. Rachel told me that she went to a concert and smoked marijuana with her brother and Evan. She seemed to be testing me to see if I'd disapprove. Of course I did, but I tried to put it into a medical context rather than acting in loco parentis. The truth is that it wasn't very cleanly done on my part and I'm afraid that she'll close that part of her life to me now. Rachel was interested in how much her improvement is related to the somatic treatment and how much is a result of her conscious effort. I told her that it was likely that she would have to continue the fluoxetine for some time before cutting back.

Tuesday, February 17, 1998
3 pm. Eighth Session with Rachel Tanner. Rachel has suffered a setback. Her hair is disheveled--suspicious looking. She's back to ritualized counting and hair pulling. She came in with dark circles under the eyes and she looks like she's lost weight. Rachel was also antagonistic towards me during the session. She blames me for allowing her to go back to school before she was really ready. She's reacting to the stresses of school by reverting to her old OCD habits; although the fluoxetine is clearly helping her conquer the OCD when she puts her mind to it, it's easier to fall back into comforting rituals. If the next session is like this one, I'd like to consider increasing her dosage from 20 mg to 30 mg. I wasn't about to play into her efforts to blame me for the stress of school, especially because Rachel also seemed more closed this time, less trusting perhaps. I decided not to probe at all but rather to focus on some guided relaxation exercises instead. I tried to make her understand that OCD is something that she will have to be vigilant against. She has conquered it before and she can again, but she has to be aware that if she isn't on her guard, it can creep up on her. She's been coping with her stress by using ritualized behaviors for a long time now, and it isn't something that's just going to go away, even with drugs. The last time I saw Rachel was before my vacation on January 6th. That's a month and a half ago. If I was seeing Rachel more regularly, we could have caught this before it got so bad. I must urge Rachel not to cancel her sessions.

Friday, March 27, 1998
3 pm. Ninth Session with Rachel Tanner. I think Rachel is turning into a success story. She seems to have come to grips with the rituals in her life. Although she hasn't eliminated them entirely, I believe that the Fluoxetine has enabled her to reduce their obsessional quality. She's achieving some success in her return to school and now she's interested in broadening her social contacts. She feels somewhat freer with her writing--the breaks I suggested seem to help--and she did well on her tests. Her hardest class is a speech class; she has difficulty preparing for public performance. She was videotaped making a presentation and she noticed that she fidgeted a lot, playing with the broken trim on the podium. Actually, I've seen myself lecturing on videotape and it just served to prove to me that there are situations where one can have too much self knowledge! Today she came to her session dressed to kill. She had clearly dressed with a great deal of care and the effect was really somewhat provocative. She claimed that it was a test to see if she could generate some attention from me--sexually charged attention is clearly what she was aiming for--before trying it on the population at large. I think she will get the attention that she's seeking. She's lost some weight, and although she was never overweight, it's now obvious that she really has quite a striking figure. It doesn't hurt now that I see her in something other than the baggy sweatshirts that used to characterize her dress. I must be attentive, however, to the possibility that she might overdo the weight loss. We talked about the possibility of ending therapy at some point, although not in the immediate future. I tried to elicit from Rachel some of her goals for therapy--what it is that she's hoping for that she feels she eludes her right now. Rachel said that she desires a feeling of being "normal" although she doesn't know what that feeling really entails. She said that she's lonely, and wants friends and a career. Unsaid but palpable was her desire for a romantic relationship. Now that her immediate OCD problems are under control, I suspect that we can begin to reach the issues that really plague Rachel, and it is to those foundational issues that we should now direct our attention.

Friday, April 10, 1998
3 pm. Tenth Session with Rachel Tanner. Rachel is on Spring Break and she is going to have dinner tonight with her brother Michael and Michael's roomate Evan whom Rachel has a crush on. Rachel clearly loves her younger brother, but she thinks of him as a clever fabricator who specializes in bullshitting others. In person, however, Rachel believes that she can read his facial expressions to discern the truth. Rachel has started going to the creative writing group that meets in Mattie's house. She feels comfortable there and believes that she can write without compulsively rewriting and editing because they generally like what she produces and she doesn't feel like she's being graded or judged. We talked a bit about her memories of her mother and her recollections of her mother's OCD symptoms. She remembers that her mother spent a lot of time inside, rocking in a chair. She also remembers that she would walk endlessly around the house, humming to herself. Rachel now thinks she was counting her steps. Rachel thought her mother's behavior was completely normal until kids at school started to tease Michael, who reacted hotly. Rachel's father apparently went and physically intimidated the parents of one of the teasing kids. Rachel hates her father. Except for her mother's funeral, Rachel hasn't seen him in eight years. Rachel was able to reach back and pull out some memories of him. She remembers things that she now interprets to mean that her father would sexually brutalize her mother and place inordinate sexual demands upon her. She remembers walking in on her parents having sex when she was about eleven. She remembers seeing them both dressed, with her mother on her hands and knees on the floor and with her father engaged in intercourse from the rear. She remembers that her father had her mother's hair wrapped in his hand and he was pulling hard on it, twisting her mother's neck around. Her mother had a wild expression on her face. Although Rachel indicated that her father's sexual activity with her mother was consensual, Rachel seems to believe that he dominated and controlled her in a way that was loathsome. I pressed, and Rachel told me that her father molested her once by putting her hand on his penis while he ejaculated. She insisted that it was only that one time. She wanted to know whether she could "blame" her OCD on the molestation by her father. While I explained that it wasn't that simple, I did point out that she had a lot of anger as a result of that relationship and that unresolved anger towards a parent could interfere with other relationships and with her own self esteem.

Friday, April 24, 1998
3 pm. Eleventh Session with Rachel Tanner. Rachel is clearly responding well to the Fluoxetine, although she has not effected a complete cure. Her rituals are increased by external stressors and she has replaced the initial rituals with other, less intrusive ones. So she has successfully reduced the burden of the rituals without exactly eliminating them. She commented on the changes I made to my office arrangement of chairs, and although she quickly adjusted, she was momentarily discomfited by the violation of her expectations. I asked Rachel about the dinner she was excited about during our last session with her brother and his roommate. She said it went well, although she wasn't invited to accompany them as they went out that night. When they got home that night, they were fairly drunk. Rachel heard them and, intending to get a reaction out of Evan, she decided to dress provocatively and hope to be caught as she went to the bathroom. She got the appreciative reaction she was seeking. She described revealing herself in that manner as very exciting. I feel somewhat protective towards Rachel and I probably overreacted when she told me what she'd done. I was concerned that the move she made on Evan sounded like a repeat of the move she made a couple of years ago when she wanted to lose her virginity and ended up getting raped and I cautioned her accordingly. We talked about OCD in relation to the movie "As Good As It Gets." Rachel thought that the portrayal of OCD was shallow and she didn't believe the reversal of the Jack Nicholson character's obsession with contamination when he was asked to keep a dog in his house. But the movie has done a lot to put OCD on the map, so to speak. Rachel wrote a sex-reversal essay for her writing group where her male character suffered from OCD. This brought up a discussion of the condition which resulted in Rachel "coming out of the closet" with respect to her own OCD. Rachel said that she had been testing the group by putting the behaviors into her character; the group apparently passed. After her session, I read the sex-reversal essay that Rachel wrote. Mostly, it involves a grooming ritual modified to suit a man. Clearly, she's exploring OCD rituals in the context of male behavior. It is interesting that it is easy to tell that it was written by a woman.

Friday, May 15, 1998
3 pm. Twelfth Session with Rachel Tanner. Rachel wrote a poem about her OCD, perfectionism, and her mother's suicide. The poem sparked a discussion about Rachel's childhood. Rachel says that she feels she was always trying to please everyone around her. Her father was rarely happy the behavior of anyone in his family, so she gave up trying to please him. But her mother leaned on her. Rachel said that, towards the end, she felt like she was her mother's mother. Rachel believes that she was robbed of her childhood. I hadn't realized how incapacitated Rachel's mother was towards the end of her life. Comparing herself to her mother, Rachel sees how much more competent she is than her mother was. She says that her mother was jealous of Rachel's competence and responsibility. I told Rachel that the obligation she felt to somehow compensate for her mother's deficiencies probably contributed to her obsessions. The rituals were designed as a system to guarantee methodical behavior which would produce a successful outcome. And it worked for a while, but when they failed to work, fault was found in the rituals themselves. More and more complexity was added to make up for perceived deficiencies in the rituals. And then the rituals were too complex to be performed properly, so any failure could be blamed on an improperly conducted ritual. And, once she accepted the causal connection between the rituals and the outcome, Rachel could take the blame for any harm, even those that logically she could have nothing to do with. At one point, Rachel felt overwhelmed and we changed the subject. She's enjoying her yoga class--she even proselytized for it. And she wrote her future vision of herself which she read to me. It was quite realistic, actually. She sees herself mostly independent of therapy, although still on medication. In her imagined future, she is living in Sausalito and doing poetry readings in bookstores. Her grandmother moved away to take care of her sick sister leaving her and her brother alone. And she imagines that she will still have rituals, although she says that she controls the OCD and not the other way around.

Friday, June 19, 1998
3 pm. Thirteenth Session with Rachel Tanner. Rachel finished up school. She told me about an incident which disturbed her. She went into a public restroom and saw an unflushed toilet filled with someone else's urine. Smelling it--and the fact that she was able to smell it--made her believe that contaminated urine molecules were infiltrating themselves into her body. She felt panicky and left hurriedly, without using the facilities. I told Rachel that I didn't think it was very serious--just one of life's daily challenges which she has to learn to face. We talked about trying to overcome that particular fear, and I think Rachel believes that she now has the tools to confront that same situation in the future. Near the end of the session, Rachel offered to give me a manicure. I'd never had one, and I didn't see any particular harm in it. In fact, I thought there might be some benefit in giving Rachel control over somebody else's hands. But when she actually had my hand in warm soapy water and was caressing it, I found it strangely erotic--even sexually so. I got the impression that was Rachel's goal; she seemed to be trying to sexually stimulate me through a manicure. It made me uncomfortable--I felt as if I was being unprofessional. Rachel seemed to enjoy my unease. She asked if she could give me a manicure concurrently with all her sessions. I, of course, declined.

Friday, July 10, 1998
3 pm. Fourteenth Session with Rachel Tanner. Rachel is taking steps to conquer her fear of contamination from public facilities--she was able to use the pool and the shower at school. I was actually quite impressed. When I talked about her inability to use public bathrooms, Rachel told me that she had reorganized her life around her phobia by carefully planning her bathroom trips and limiting her fluid intake. I tried to use an exposure technique when I suggested that she try to use the bathroom in the building down the hall, but I might have pushed her too hard. She took it poorly and angrily rejected my suggestion. She took my efforts to get her to use a public restroom as manipulative game playing and angrily wanted to walk out of the session. I prevailed upon her to remain and showed her an Internet site which offers a sense of community for sufferers of OCD. She read for a while and, seeing a number of posts with different medication options, questioned me on my choice of Prozac as a somatic treatment for her. By the time I finished discussing the various options in medication, she had lost much of her anger and we ended the session. I was surprised by how volatile she was. In our earlier sessions, Rachel was much more timid and nervous. Actually, I think that her ability to assert herself and her anger shows a degree of progress, although obviously I'd like it to be directed elsewhere. When Rachel was discussing showering at the school, she said that she caught Carla, her Human Sexuality teacher, staring at her. When Rachel caught her eye, Carla gave Rachel a mischievous look that gave Rachel chills. I suspect that Carla's actions were completely innocent and that Rachel's heightened sensitivity to the experience of being in a public shower caused her to read more into a glance and a smile than were actually there. An interesting side note is the surprising fact that Rachel took a shower in the public locker room at all. I suspect that most people, if uncomfortable about taking a public shower, would just dry off and go home to shower. I suspect that Rachel, however, was so conscious of the possible dirt and germs in the swimming pool water, that the prospect of a public shower was less repulsive than the idea of staying "contaminated" with the water from the public pool.

Friday, July 24, 1998
3 pm. Fifteenth Session with Rachel Tanner. Rachel has entered into a sexual relationship with Carla, her human sexuality teacher. Rachel obviously enjoyed the experience--she came in grinning with excitement over the prospect of sharing this juicy tidbit with me. I was surprised at the ease with which Rachel was able to accept the touch of another. But she seemed to have had no difficulties in that regard, and no overriding contamination issue, either. She said the fact that it was poolside helped--something about all that water being right there. Rachel basically described an episode of mutual masturbation rather than cunnilingus--but I did urge her to take active measures to avoid sexually transmitted diseases. There are obvious ethical issues involved in a relationship between teacher and student, but I didn't bring them up. I also decided to be supportive at the moment of the relationship as a whole. Although Rachel has always displayed a healthy interest in sex, any positive sexual experience is likely to assist her in conquering her OCD. I also tried to reassure Rachel that homosexual experimentation does not necessarily equate to a lifelong commitment to homosexuality. We talked a bit about the upcoming third anniversary of her mother's death. Rachel believes that her mother leaned on her grandmother for emotional support or at least "the opportunity to vegetate," as Rachel put it. Rachel thanked me for directing her to an OCD site on the Internet. But she read a description posted by someone with doubting disorder and now she wonders if those thought patterns might happen to her. But it's just a passing thought rather than a serious concern. We talked a bit about rationally assessing risks rather than allowing OCD to enforce risk averse behavior. The example that Rachel used was her fear of contamination as related to kissing. We talked about what she was afraid of--germ contamination from saliva--and talked about how to look at the reality of the situation and ignore the unreasonable fear.

Friday, August 14, 1998
3 pm. Sixteenth Session with Rachel Tanner. Rachel's relationship with Carla is developing depth. Rachel tried to kiss Carla and couldn't. She threw up instead. But that lead to a frank discussion with Carla about Rachel's battle with OCD. Carla seemed patient and caring. She also seems more than willing to help Rachel through her difficulties with intimacy. Rachel has a host of concerns, most of them are typical for someone starting a new relationship and for someone unsure about their sexual orientation. I see my intervention into those issues as less important than into issues which arise out of the OCD. For example, I'm not certain that Rachel's sexual orientation is really exclusively directed towards women. That would be inconsistent with the sexual fantasies she described as revolving around her brother's roommate. Rachel has very little experience with sex. But she's clearly enjoying the onset of sexual intimacy with Carla, and Carla appears to have the patience to awaken Rachel's sexuality. I wouldn't be surprised if Rachel outgrows Carla and uses what she's learned in that relationship to take on a heterosexual relationship. Of course, I could be absolutely wrong on that point--it's really just a hunch. I pointed out that Rachel was making remarkable progress in her willingness to undertake new experiences--that's a considerable understatement! I also noted that her nails now are less ravaged than at any time since she began seeing me. Rachel is thinking about moving out of her grandmother's home and getting a job, preferably on campus. Rachel also told me that she and Michael had worked over the last year on a memorial service for their mother to commemorate the third anniversary of her death. The memorial service was emotional for Rachel but perhaps it helped bring her some sense of closure to her mother's death.

Friday, September 11, 1998
3 pm. Seventeenth Session with Rachel Tanner. Apparently, Rachel's relationship with Carla has ended. Rachel sees everything in negative terms right now: she had certain sexual limitations which caused her to fail in the relationship. I urged her to see things in a more positive light: she was able to trust Carla and engage in many forms of sexual intimacy, she was able to reveal her OCD to another person, and the experience will be of enormous value to the next relationship she has. Perhaps Rachel can see it that way over time. But the biggest enemy Rachel has is free time. When she's not busy, and she's of a certain frame of mind, she can allow her OCD to become quite destructive. Rachel pulled off a scarf on her head that she had been wearing and revealed a hideous bald patch over her left temple. I'm surprised I hadn't noticed it. She suffers from trichotillomania--I remember learning from her grandmother a while ago that Rachel had pulled out all her pubic hair. She told me how she finds the root end of each hair she pulls and lines them up and presses them into her book. While Rachel seemed interested in increasing her medication, I'm hoping to go in the other direction. So I told her to be consciously aware of her propensity to pull her hair and to guard against it both by pulling her hair back or otherwise protecting it, and by keeping a profusion of worry toys around her with which she can fiddle. In a week, school starts and I'm hopeful that this will become less of an issue. I also hope that she doesn't find herself in one of Carla's classes.

Friday, October 16, 1998
3 pm. Eighteenth Session with Rachel Tanner. I felt Rachel was slipping away from me and back into her old OCD habits. She's been a mess since the incident with Carla, and a few bouts of illness have not improved matters much. Her physical appearance was poor. She's had an outbreak of psoriasis which I think may be stress-related. She's also still trying to recover from a sinus infection. I think Carla, school, and a tense relationship with her grandmother are feeding her stress. I first prescribed Prozac to Rachel on November 4, 1997. I decided today to increase the dosage to 40 mg. from 20. I'd like Rachel to be able to reduce the hair pulling and finger picking which, in turn, seem to undermine her self-esteem. Rachel seemed relieved when I suggested increasing her meds. I think she could feel herself slipping and hopes that the increase in her medication can stop the slide. After the session, I had a brief conversation with Dr. Malcolm, her primary care physician. He concurred about the possible reason for the current outbreak of psoriasis. I advised him to be on the lookout for Prozac-related side effects.

Friday, November 6, 1998
12 pm. Telephone Conversation with Rachel Tanner. Rachel is still sick, but we spoke by telephone. Her grandmother has decided to go back to Germany and, although she's still willing to provide some support to Rachel, Rachel is going to have to find another living situation. She's exploring her options in a reasonable way, although it seems that she's really hoping that her brother will invite her to come and live with him. Rachel told me that she has avoided pulling out her hair for 8 days now, and I believe that she's experiencing some positive benefits from the fluoxetine she's taking.

Friday, November 20, 1998
3 pm. Nineteenth Session with Rachel Tanner. Physically, Rachel has improved quite a lot. She's no longer ill, and she's reduced her hair pulling. She showed me that the ugly bald patch has been replaced by hair stubble. She's decided to move in with her brother, Evan, and she's going to be living in the laundry room in their flat. Although unglamorous, it's cheap and it's with her brother, so Rachel is happy. As her grandmother is moving to Germany in December, all these changes in Rachel's life are quite imminent. Rachel has an interest in yoga which she tried to pass on to me. But just watching her do a few exercises made my spine hurt. She's planning on taking public transit frequently to get to yoga classes. When I asked about possible contamination issues she might have with public transportation, she said that she's able to handle it. I hope that turns out to be true. I would like to see Rachel become as independent as possible.


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