Transcript of 4th Session between Charles Balis, M.D. and Ms. Rachel Tanner, Tuesday, November 4, 1997 at 3:00 pm.

Dr. Balis: Come in, Rachel.
Ms. Tanner: Hello, Doctor.
Dr. Balis: How are you?
Ms. Tanner: Not that great.
Dr. Balis: I'm listening.
Ms. Tanner: Well, I brought back the tape that we made last time. I wasn't sure if I was supposed to keep it. You can see how much I listened to it.
Dr. Balis: Did it help?
Ms. Tanner: Remember I told you about counting the steps to my room and all that? Well, just from making the tape and listening to it those few times, I tried not counting. Then I tried counting by twos. By the time I got to my room, it was 28 steps, and that was okay because it was an even number.
Dr. Balis: You replaced one counting ritual with another.
Ms. Tanner: Yes, but I proved that it could be done or changed. Then I called Michael to check up on him, and he said everything in his life was cool right now. I probably shouldn't have called him, but I wanted to know for sure. So then, I tried only counting the stairs and forgetting the rest. As long as there are thirteen steps, then everything is cool.
Dr. Balis: You walked up the stairs in this building, didn't you?
Ms. Tanner: Yes, but once I learn how many steps there are, it's just a reassurance thing that I count the same number each time. There are two steps to get into the lobby of your building, there are four stories with eighteen steps to each floor. That makes seventy-four stairs altogether--again, an even number.
Dr. Balis: Hmm...
Ms. Tanner: There are four steps to the library and three to the Hairport. Hey! I suppose I could take the handicapped ramp and avoid steps all together!
Dr. Balis: Great idea! Then there's nothing to count. Rachel, I'm curious. There are twenty tally marks on this tape box, so have you listened to it twenty times? How would you say you distributed your listening throughout the last two week, evenly?
Ms. Tanner: No. Those were all from the first three days, then I didn't listen at all.
Dr. Balis: Why not?
Ms. Tanner: Gram overheard it one day and had a fit. She wanted me to explain why we had made a tape with such nonsense on it. I told her about my counting things. She had no idea.
Dr. Balis: Tell me more about her reaction.
Ms. Tanner: I just let it all out. I told her about my fears about Michael and how I have to count and brush and everything. She listened the whole time, raising her eyebrows like she does but not saying anything. When I was done, she looked like she was going to cry. She said my mom's name in a breathy sort of way, "Katrina..." And then she talked about Mom and how troubled she was at my age. Gram said she had hoped that I wouldn't take on Mom's possessions--that's the way she put it--but now she sees that I have.
Dr. Balis: Did you learn anything new about your mother?
Ms. Tanner: Yes. Gram said whenever she and Grandpa tried to entertain, Mom would come in beforehand and commandeer. She would dictate to her parents where the guests could and couldn't go in the house. Mom loved to help get out the best dishes, but that was because she didn't want anyone but the family using the everyday dishes--the contamination thing again. She'd even move one particular chair into her bedroom, because she didn't want anyone to sit in it. That was a cool discovery, because that same chair is in my bedroom. It's mine now. But basically, Gram talked about how worried she used to be about Mom--her nervous little bird. She calls me that too, affectionately. She said one thing that freaked me out.
Dr. Balis: What is that?
Ms. Tanner: She asked how she could help me.
Dr. Balis: Why did that bother you?
Ms. Tanner: Gram doesn't usually reach out to me like that. And it made me think about my mother. Then, I was thinking about how tortured my grandmother must have been most of her life with two OCDers to worry about. I just started sobbing. I wish there was something she could do! I wish there was something you could do!
Dr. Balis: Rachel...
Ms. Tanner: I'm sorry. I feel like since I've been coming to you, it's been bringing things to the surface. I keep trying to do what you ask me to, but I'm not sure it's helping. I want the noise in my head to go away! Now that I'm not working, I have all this time to think. Just when I finish a ritual, I start the thoughts over again to make sure that there's nothing left to worry about.
Dr. Balis: Rachel, I'm going to review what we have tried so far. First of all, the fact that you keep honoring your appointments is a very positive accomplishment. You responded well to the relaxation we tried in my office, and you said that the tape is working for you at home. We made a tape to reinforce the notion that there's no relationship between your rituals and your brother's well-being. You were able to open up communication about your OCD with your grandmother. You said you had been writing in your journal every day--it gives you something to do besides nervous things. I suspect that your journal reveals much about your progress that you don't even realize. Have you read the first few entries lately?
Ms. Tanner: No.
Dr. Balis: I want to discuss the possibility of trying something new with you. Rachel, there are medications available that have proved quite effective in relieving the tension and preoccupation that OCD can create. The best description I've heard from patients is that medication coupled with therapy can give you something equivalent to water-wings--some support until you learn to swim on your own. The analogy sort of works, except that I know that you are quite the swimmer to begin with. Can you see where I am headed?
Ms. Tanner: Yes, Doctor.
Dr. Balis: You indicated in your paperwork that you're not currently taking medication. Is this correct?
Ms. Tanner: Yes.
Dr. Balis: I would like to prescribe a drug called Fluoxetine. We would start with a small dose of 20 mg., possibly increasing it once we find out how you feel. It takes awhile for it to be effective. Should you ever discontinue it, it takes awhile for it to leave your system. I should also mention that there are a few possible side effects: headaches, weight loss, nausea, nervousness, sometimes insomnia. But very few people are allergic to it.
Ms. Tanner: I have no problem with all that. I have trouble sleeping as it is, and the weight loss part sounds like a plus. So, what will it do to help me?
Dr. Balis: This drug should reduce the intensity of your obsessive thoughts. It typically gives more relief the longer you take it, although we're looking at a long range treatment program with a goal of eventually discontinuing the medication.
Ms. Tanner: Why didn't my regular doctor prescribe it to me?
Dr. Balis: Did your physician know as much as I do about your condition?
Ms. Tanner: No, now that you mention it.
Dr. Balis: I can't speak for your doctor, but some physicians of late are being accused of over-prescribing this medication. And I personally believe that general practitioners should not prescribe psychiatric drugs. They rarely can do the appropriate follow-up which is essential for these types of medications. Rachel, I still have a couple more questions related to the prescription. Is there a possibility that you could be pregnant?
Ms. Tanner: No, sir!
Dr. Balis: That makes you laugh?
Ms. Tanner: Well, I'm not exactly active in that sense.
Dr. Balis: Well, it's possible that the medication could make it more difficult for you to achieve orgasm, although probably not at this low dosage. Is there any history of convulsive disorders in your family?
Ms. Tanner: Convulsions? Like epilepsy or something? No.
Dr. Balis: Do you drink alcohol?
Ms. Tanner: Never.
Dr. Balis: Then we will try the 20 mg. per day capsules.
Ms. Tanner: Capsules? Are they big bombers?
Dr. Balis: No. They are not any bigger than a large vitamin. You're going to take one a day, preferably in the morning after you have eaten a little. Do you have any questions?
Ms. Tanner: How long is it going to take before I start noticing a difference?
Dr. Balis: You might start feeling one or more of the side effects I mentioned before you feel the benefits. I want you to give it at least eight weeks, unless of course you have an adverse reaction such as a rash. If that happens, please do not hesitate to call me.
Ms. Tanner: You sure sound like you want to help me.
Dr. Balis: Of course I do, that's my job.
Ms. Tanner: This thing...this OCD is very lonely. Do any of your other patients have it?
Dr. Balis: Their treatment is confidential, just as yours is, so there isn't anything I can tell you about them. Rachel, I wanted to remind you that what you say in this office, what you write in your journal are private communications. You're free to share things with your grandmother, if you desire. You said the tape surprised her, but if you want to continue to listen to it or make a new one, it's your decision. Medication is also your decision. But I hope you don't have to hide the fact that you're taking this medication from your grandmother. Does this make sense?
Ms. Tanner: Yes. Obviously, there's a lot I don't share with her. I want to get well, that's the bottom line. I probably won't tell her at first. I want to see how it feels for awhile. For the first time in my life, I'm starting to feel more independent because of what I share with you. I feel like I'm finally acting on something that I was afraid of for so long.
Dr. Balis: That sounds very positive. It's very important that you know that talking about OCD does not make it worse. And there are a lot of people who suffer from the disorder. How have you been sleeping?
Ms. Tanner: I've had two bad nights when I didn't fall asleep right away. I get restless, so I turn on the computer and play games, or e-mail Michael, or look up stuff on the Net. Before I know it, it's two o'clock. But if Gram takes naps, so can I.
Dr. Balis: Maybe in one of your nocturnal ramblings on the Internet, you can check-in on some of the forums set up for sufferers of this disorder. You'll find you're not alone. Are you still swimming?
Ms. Tanner: Every day.
Dr. Balis: Excellent. You probably need to keep busy. And when you are not busy, relax. Are you able to relax enough to keep your hands still?
Ms. Tanner: Sometimes. I guess I have come a long way.
Dr. Balis: Baby steps. Let me write out this prescription.
Ms. Tanner: Could you call it in to the pharmacy?
Dr. Balis: Sure, if that's what you want. What pharmacy do you want me to call?
Ms. Tanner: The one in the shopping center next to that Italian market that has the great produce. D'Anelli is it called? My grandma and I shop there once a week.
Dr. Balis: That's a Walgreens, isn't it? I know the Italian place. You must eat well.
Ms. Tanner: Gram's a really good cook. I'm learning.
Dr. Balis: Rachel, call me if you have any concerns about the medication. It's also really important to continue to write in your journal. I was wondering if you would bring your journal with you next time.
Ms. Tanner: Okay. Thanks, Doctor Balis.
Dr. Balis: See you in two weeks, on November 18th. Is this time, 3 o'clock, convenient for you?
Ms. Tanner: This is fine. I'll see you on the eighteenth.
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