Psychiatry by the Dumpster: One Man's Struggle with OCD

Psychiatry by the Dumpster: One Man's Struggle with OCD

by Elias Aboujaoude
Psychiatrist and OCD specialist Elias Aboujaoude gives a poignant account of one man's struggles with severe OCD and his journey to recovery.


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Editor's Note: The following article was adapted from Compulsive Acts: A Psychiatrist’s Tales of Ritual and Obsession, published by University of California Press, Berkeley (2008).

Three Feet

In a way, George was special from day one. I can still remember Dawn, my clinic clerk, paging me at 1:45 PM, three quarters of an hour after his first scheduled appointment, to warn me: “Oh, Dr A., you’re gonna love this one!”

“Please don’t tell me the patient just showed up,” I said. “How am I supposed to do a full intake in the remaining fifteen minutes?”

“I know,” Dawn answered, “but I couldn’t just let him go. I don’t know what to say, but he’s—how should I put it—he has his reasons for being late…. He’s different, even by our standards in this clinic, and even after nine years of doing this! I had to go out into the parking lot to check him in. That should give you an idea...”

“You went to the parking lot to check him in?” I asked. “Outside?”

“Yes, outside,” Dawn answered. “He can’t come in, he says. Our door isn’t wide enough for him.”

“Our door isn’t wide enough?” I asked, questioning whether I was the right doctor for this patient. “Did he mistake us for the gastric bypass clinic? How heavy is he?”

“Oh, he’s not heavy at all,” Dawn answered. “In fact, his wife tells me he hasn’t eaten in a few days. He’s just… I don’t know…Something about his nose… He won’t let anyone or anything close to it… He was so worried about his nose, he wouldn’t even get into the car this morning.”

“How did he make it to our clinic, then?” I asked. “I thought he lived in Belmont. That’s fifteen miles away.”

“He does,” Dawn said. “He walked here. His wife drove, but George walked.”

“He walked?” I asked again. “All the way from Belmont?”

“All the way from Belmont,” Dawn repeated. “That’s why I can’t simply send him back and ask him to reschedule. Anyway, he is checked in now and waiting for you over in the far corner of the parking lot, exactly three feet from the dumpster, where, I might add, his wife spotted your old, squeaky filing cabinet and asked me to help her pull it out and put it in her trunk. I’m no doctor, but she’s not right, either… What use could she possibly have for that cabinet? Anyway, what would you like me to do now?”

“Well, I guess my only choice is to come right down,” I said. “Meet me by the dumpster.”

“OK, just remember not to get too close!” Dawn warned. “You might frighten him. And, by the way, your two o’clock is here, too.”

“Great! Is my two o’clock at least waiting in the waiting room?” I asked.

“Yes, she is,” Dawn answered. “And I told her it was going to be a long wait…”

As I approached Dawn, who was standing in the distant corner of our parking lot, I noticed George in a vacant handicap spot by our recycling dumpster. In the adjacent spot, and having managed with Dawn’s help to squeeze my old filing cabinet into her trunk, stood his wife, now trying unsuccessfully to push the trunk door shut.

George was a lean twenty-something, with wide green eyes and a sunburned face and neck, probably from having walked a very long distance in the midday sun to come see me. His grooming and hygiene left something to be desired, and his dirty fingernails and caked hair indicated more that just the wear and tear of that day’s walkathon.

His wife started the conversation off. “Dr. A., thank you for coming out here to see us,” she said, still intent on shutting her trunk door, despite one of my old filing cabinet’s legs clearly sticking out. “I know this is not standard practice, but it’s very difficult to get him through doors anymore. I read up on obsessive compulsive disorder, so I know how to diagnose it. Heck, I may even have a touch of it myself… We’re here because we were told you were a specialist in OCD. It’s urgent, Doctor! Things have gotten completely out of control since it’s grown to three feet. Three whole feet!”

“I know this is not standard practice, but it’s very difficult to get him through doors anymore."

I was intrigued by the three feet, but realized that I had not yet introduced myself to George. However, before I could formally do that, George apologetically preempted my handshake.

“I don’t mean to be rude, Doctor,” he said, “but please don’t stick your hand out. I can’t do handshakes.”

“That’s OK, I understand,” I said. “I’m pleased to meet you anyway. Your wife just said that ‘it’s grown to three feet.’ What is it that has grown to three feet, George?”

“The radius around his nose,” his wife answered, her quivering voice betraying her anxiety. “He needs that much clear space around his nose at all times. In the good old days, it used to be that nothing could come within a foot of his nose, and we used to be able to joke about it. But when the radius grew to two feet, it was anything but funny, and we started needing to make lifestyle modifications: the having to sit alone in the back seat of the car, the trying to sleep standing up like a horse, not to mention—if I may go there in your parking lot—the challenging sex….”
“He needs that much clear space around his nose at all times."

I could see Dawn’s face clearly tense up at the idea of “going there.” George’s wife’s sexual comment was clearly in poor taste for Dawn and went against her deeply ingrained prohibitions about discussing private sexual matters even in clinical conversations—that is, if you can really call a parking lot discussion about symptoms a “clinical conversation.” Dawn’s anxiety, however, found immediate release when she abruptly broke off the filing cabinet’s leg that was protruding from the trunk, then threw it inside the car, which finally enabled her to close the trunk door shut.

The sound of the trunk door shutting, and the thought of securing the old cabinet for her home, caused George’s wife’s anxiety to subside as well, and a relieved smile made its way to her face.

“However,” she continued, more at ease, “even two feet weren’t enough. It had to grow to three feet, and, at three feet, it has been, well, impossible to accommodate!”

Steering the conversation back to the principal patient, I asked, “How long has this been a problem for you, George?”

“Oh ever since… I don’t know… It sort of crept up on me,” he answered.

“Ever since his brother died,” his wife continued.

“When did that happen?” I asked.

“Two years ago,” George answered. “He died in a skiing accident.”

“I’m very sorry to hear that,” I replied.

If sex had been a difficult subject to discuss in the parking lot, death would have been even more so, so I had to ask George, “I know this is hard for you, but can you try once more to come up to my office so we can continue this important conversation in private?”

“I can’t. I’m sorry,” George answered, cautiously shaking his head. “Doorways are difficult for me. Hallways are challenging. And elevators are out of the question.”

“Nothing personal, Doctor,” George’s wife continued. “His father was visiting from Europe where he lives last month. We hadn’t seen him in two years. Well, George wouldn’t even give him a hug! All he could do was wave hi from a safe distance when he arrived at our house and wave goodbye when we dropped him off at the airport…”

Seeing that the entire first meeting would probably have to be conducted outside, I wanted to make myself more comfortable. I approached his wife’s car to try to lean against the door, only slightly moving in George’s direction in the process. George responded briskly, first stretching his arms out, then turning on his feet in a 360-degree circle, his arms fully extended. The move resembled a disc rotating on its axis, and its purpose, I surmised, was to make sure that the required radius of safety was not violated by my sudden movement, and that I did not put his nose in any danger.

Sensing that I may have inadvertently increased George’s anxiety, I tried to give him a little break and addressed my next question to his wife instead.

“You said you might have a touch of OCD, too,” I said. “Tell me about it.”

“Well, it’s really just a touch,” she said. “Nothing like this! I don’t worry about injuring my nose, although I should! I broke it twice already, once in a car accident, and once in a diving injury. My OCD, if we may call it that, actually makes some sense… It’s about making sure that I don’t run out of important things. ‘What if I need it one day?’ I always ask myself when I consider, or George makes me consider, throwing something out. And this simple question is usually enough to make me want to save the item, whatever it is. You can understand, then, how I built up my collection of pots and pans and cooking magazines and the cabinets where I eventually hope to store them all. Did I mention cooking magazines? This is probably my biggest weakness!”

“Indeed,” George agreed, gently nodding his head in agreement. “She has so many cooking magazines all over the kitchen, she can’t make it to the stove to cook!” he added, smiling at the irony.

“That’s right,” his wife agreed. “I honestly don’t remember the last time I cooked a meal for this poor man.”
When the radius grew to two feet, he couldn’t even eat pizza, so he started insisting on soups and fluids, served in plastic bowls without a spoon.

“But despite the mess in the kitchen,” she added, “we still eat well—or ate well—I should say, until his symptoms began. When he was at one foot, he already couldn’t use utensils, so I would buy him pizza which he would eat alone in his office. We lived on pizza for months because it didn’t require a fork and a knife to eat. I would ask him, ‘George, how come the pointy end of a pizza wedge is OK, but you can’t use a knife and fork?’ and he would say that something about metal approaching his nose was much scarier than the pointy end of the pizza wedge. Well, I thought it was kind of tragic, especially for someone who loved to eat and appreciated food so much. But oh how I miss those days now! You see, when the radius grew to two feet, he couldn’t even eat pizza, so he started insisting on soups and fluids, served in plastic bowls without a spoon. Later, when the radius grew to three feet, he started avoiding coming home altogether. He thought it was too much of a hazard, with all my stacks of cooking magazines and other stuff strewn all over the house. He didn’t want to trip and fall and hurt his nose, he said. So he now rents a studio nearby and eats, oh, I don’t know what he eats, or if he eats… Look at how thin he’s gotten!”

George did appear thin, but more than his low weight, it was his disheveled appearance that marked him as unhealthy, so I asked him, “What about basic activities of daily living besides eating? Toileting and hygiene, for instance?”

“This is really embarrassing, Doctor,” George answered, looking down and away from me.

“I can’t shower anymore. I feel the showerhead is about to attack me. We even had a plumber come in to replace it. He said he would have to install the showerhead in our neighbors’ kitchen next door if he had to adhere to my specifications of how far it should be from my head when I’m standing in the tub! I know it’s crazy, Doctor, but I really can’t help worrying about it.”
“I can’t shower anymore. I feel the showerhead is about to attack me."

“Worrying about things that don’t make sense, and constantly checking to make sure one is safe, are common symptoms in OCD,” I said. “It doesn’t mean you’re crazy. It means you have OCD and that is only a small part of who you are. The good news is that for many patients OCD is very responsive to treatment, so I’m glad you made the decision to come here today.”

It is important during a first psychiatric meeting to try to get a fuller sense of the patient than his symptoms alone, so I tried to enquire about George’s hobbies and work experience next. Unfortunately, the conversation would always come back to OCD. “What do you enjoy doing in your free time?” I asked. “Tell me more about the part of you that doesn’t have OCD.”

“Well, I used to sing in church,” George answered, “but I’ve had to give that up, too. The idea of standing in front of a microphone is enough to make me mute with anxiety!”

“How about work, George?” I asked.

“I used to work in a large advertising firm,” he answered. “I had to give that up, too. My cubicle got too small for my nose…”

George smiled at the visual—an expanding nose in a shrinking cubicle—and I smiled, too, appreciating this young man’s stubborn sense of humor, still evident despite the obvious stress he was under.

But many pieces of George’s life and history were still unknown to me, and I could feel a hundred questions racing through my mind, competing for my attention and begging to be asked. By that point, though, I was very late for my two o’clock appointment, still patiently waiting for me, so I had to leave George and his wife in the parking lot after getting a promise that they would return the following day so we could continue our “first meeting.”

I did not leave them alone, though. I left them with Dawn, hoping that she would use her powers of conviction to get George inside the car.

“If I can get that old oversized filing cabinet into your wife’s trunk and manage to shut the door, I think I can get you into the car, too,” she said to George as I walked away. I then cringed at what she might have in mind for George’s trip back home as I overheard her ordering George’s wife to open the sunroof…

"Other than this preoccupation with my nose..."

For our second meeting the following day, George still walked from his apartment to my clinic. With much encouragement from his wife and Dawn, George was able to enter through the building’s doors and climb the stairs to the clinic area, after performing a checking regimen that took a whole hour to complete: With each step he took from the building’s main door to my office, George would make a 360-degree turn on his feet, his arms fully stretched out to clear the space around him. Dawn led his wife to the waiting room so I could meet with George privately.

Once inside my office, George used one hand to move a heavy wooden armchair from one corner of the room to the center, using the other hand as protective shield for his nose in case he moved the chair too close to his face. He then very cautiously sat in the chair. As he did that, I found myself rolling my chair back into the corner to give him additional security.

“Why me?” was his first question.

“I wish I had a satisfactory answer for you,” I said, “but, like so many other psychiatric and medical illnesses we see, we are much better at treating them than at knowing exactly why a particular person develops a particular symptom.”

“Did I somehow catch it from her?” he asked, referring to his wife, but appearing suspicious about the premise of his question as though he knew beforehand that the answer would be “no.” “But I don’t hoard,” he quickly added. “In fact, I’m the anti-hoarder.”
“Did I somehow catch it from her?” he asked.

“You cannot ‘catch’ OCD this way, George,” I said. “You would, however, have a genetic vulnerability to developing OCD if you had a close blood relative with it. However, even when OCD does cluster in families, its symptoms can vary greatly among family members.”

“Well, I don’t have any biological relatives with it, as far as I know,” George quickly said.

“Speaking of ‘catching’ things,” I said, “do you spend a lot of time worrying about contamination or pollution? How about frequent checking that doesn’t involve your nose? Any excessive cleaning, counting, touching, arranging, or worrying about other body parts besides your nose, now or in the past?”

“Never,” George answered. “Other than this preoccupation with my nose, I’ve always been a pretty laid back, relaxed guy.”

“Do you worry that your nose may be weak or somehow deformed and in need of protection?” I asked. “Do you think it looks abnormal?”

“No, I think my nose looks just fine as it is now,” George replied. “I’m very happy with it. I just want to keep it that way!”

“Do you have any reason to worry that it might not stay that way?” I asked. “Are you prone to accidents, for example? Have you ever seriously injured your nose or any other body part before?”

“Not really,” George answered. “I’ve always been the cautious choirboy and high school debater kind of guy rather than the contact sports type.”

Seeing that it was not the memory of some old physical trauma that was making George worried today about hurting himself, I wondered about a trauma he may have witnessed involving someone else, or even an emotional trauma. Thinking back to our first meeting when his wife related the onset of George’s OCD symptoms to losing his brother in a skiing accident two years ago, I said, “Tell me about your brother, George. Were you close?”

“Yes, very,” George answered, his eyes looking down and away. “I was supposed to go with him on his skiing trip, but a choir event kept me back.”

“I’m sorry to hear about what happened to him,” I said. “Is it true that your OCD symptoms began shortly thereafter?”

“As I said, it sort of crept up on me,” he answered, “but I would say sometime around then is when I started frequently checking my nose in the mirror to make sure that it was OK.”

The striking coincidence between the onset of George’s OCD symptoms and the loss of his brother is rich in meaning and symbolism. It is relatively common for patients with OCD to experience their first symptoms, or to relapse after a symptom-free period, as a function of external stress. But, beyond that, were George’s specific symptoms somehow determined by the nature of the stress? Could the unexpected loss of a young, healthy brother to a fatal accident have made George overly vigilant about his own environment and in desperate need to try to control it to prevent a similar sudden tragedy from happening to him?

However, before I could expound further on this hypothesis with George, we heard a light knock on the door. George’s wife then gently walked in, careful not to swing the door fully open in a way that might disturb George, who was still sitting in a chair in the center of the room. She was carrying an oversized bag which she carefully deposited on the floor against the wall. She then stood practically stuck to the wall.

“I thought I had given you enough time alone and was burning to ask you some questions about my role in George’s treatment,” she said. “For example, I feel sometimes like I’m colluding with him and making things worse, as when I agreed to unhinge and remove the French doors between the dining room and the living room to make the passageway safer for his nose. Should I have just said ‘no’ and expected George to deal with the anxiety of navigating the doorway? Did I do more harm than good by giving in to his OCD?”

“I think you raise a very good question,” I said. “It’s a difficult balance that you’re being asked to strike. On the one hand, it’s your natural instinct to help your husband when he asks for it, but, on the other hand, you know that giving in to his OCD can perpetuate his symptoms and allow him not to address them. In my opinion, the best way to handle this is to try to accommodate the severe OCD fears which, if not allayed, would paralyze him. However, you should try to avoid giving in to those lesser fears that you think he can handle on his own. There’s a way to do this that teaches him how to work through his anxiety and be more independent.”

As I tried to explain to George’s wife her role in treating her husband’s OCD symptoms, I couldn’t help but think of a possible indirect role she may have played in causing them. From my previous conversations with George about his wife, and from what I witnessed in the parking lot when she rescued a useless filing cabinet from the dumpster and took it home, it was relatively clear that George’s wife suffered from a form of OCD, too, manifesting primarily in hoarding behavior. Could it be that her collections of useless objects and magazines that are cluttering the house were even more obstructive to George than the French doors in the example she gave? Would another way to understand George’s specific symptom and his need for space be that it’s an unconscious attack against his wife for the hoarding that had severely cluttered their lives? By being so debilitated by objects that stick out, and by eventually needing to leave the house because of it, was George signaling to his wife his strong objection to the state of the house and her inability to fully acknowledge the extent of her own illness and get treatment for it?
A Freudian psychiatrist might read in George’s symptoms—and expose to him in the course of therapy—the following unconscious message towards his wife: It’s time for you to give the house an overdue cleaning, and it’s time for you to admit that you have OCD yourself and to do something about it.
A Freudian psychiatrist might read in George’s symptoms—and expose to him in the course of therapy—the following unconscious message towards his wife: It’s time for you to give the house an overdue cleaning, and it’s time for you to admit that you have OCD yourself and to do something about it.

It was, of course, a delicate dance. While I wanted to try to point out features of George’s wife’s behavior that might have promoted and contributed to her husband’s symptoms, I could not afford to forget that George, not his wife, was my patient. It wasn’t my role to diagnose or treat her, especially since all that she was willing to accept was that she had only a “touch” of OCD. Still, I would have liked to gently explain to her the possible interplay between her “touch” of OCD and her husband’s full-blown condition, but another knock on my door followed by Dawn making her entry interrupted me.

Dawn was very careful not to swing the door fully open. Once inside, she positioned herself right along the wall, close to George’s wife, adding to the drama of the “set.” As it now stood, the configuration of bodies and furniture in my office was as follows: George in his chair in the exact center of the room, me in mine tucked in the far corner opposite the door, George’s wife standing completely vertically against the wall, and Dawn adopting the same position on the other side of the door from her. Between the two women, and also stuck to the wall, was George’s wife’s oversized bag.

“I’m not being unreasonable because I haven’t eaten all day,” Dawn said, referring to her annual Lent fast which she had just begun, “but we have a problem on our hands, and we better address this now.” Then, looking alternately at George’s wife and at the bag on the floor, she added, “You cannot do that. I saw you. You cannot take the cooking magazines from our waiting room. What’s in the dumpster outside is fair game, but not what’s inside the building! We can help you if you need help, but you cannot be taking our magazines, especially since we work hard to keep our reading material up to date compared to other clinics!”

An uncomfortable silence descended on the room which George finally tried to break with an attempt at humor. “I guess you have kleptomania on top of hoarding, my dear,” he said, gently shaking his head and chuckling briefly.
“I guess you have kleptomania on top of hoarding, my dear.”

But there was nothing humorous in any of this for his wife. Her face turned deep red and her eyes tried hard to avoid the other three sets of eyes in the room. Seeing how much embarrassment she had caused, Dawn quickly sought to assuage her guilt. “But I promise to save any old issues for you if you want!” she quickly added.

"I cannot even hug my wife"

George did not wish to approach his OCD as a novel with villains and victims. He didn’t see a very convincing connection between his brother’s untimely death or his wife’s hoarding problem on the one hand, and the onset of his OCD symptoms or the nature of these symptoms on the other. The most he would agree to was that the overall level of stress that his brother’s death and his wife’s condition had caused him somehow made his vulnerability to OCD finally express itself.

And I basically agreed. I felt that pursuing these impossible-to-prove associations too forcefully against George’s stated preference could, paradoxically, lead him to attribute meaning to symptoms that he saw as essentially meaningless and indefensible. Following a psychoanalytic therapy approach that imbued symptoms with a rational dimension through cause and effect linkages ran the risk of making them “meaningful” and, hence, perhaps worthy of holding on to.

Rather, the idea of OCD as a chemical imbalance that happens for reasons that we do not fully understand is what resonated with George, in part because it took the blame away: It was no longer a personal failing on his part, nor was it his brother’s or wife’s fault. He had researched the serotonin hypothesis for OCD and was much more in favor of a chemical solution to what he viewed as essentially a chemical problem.

“So what SSRI are you starting me on?” George asked at the beginning of our third meeting, before I had fully discussed pharmacological treatments with him.

“I’m very impressed,” I said. “It looks like you’ve done your homework. Do you know how these medications work?”

“Something about serotonin,” George answered.

“Indeed,” I said. “Selective serotonin reuptake inhibitors, or SSRIs, work by increasing levels of serotonin in the brain.”

“What’s the likelihood of them working?” he asked.

“The response rate is around 50 to 60 percent, and it seems similar across all SSRIs,” I said.

“So how do you decide which one to give, then?” he asked.

“Well, I decide in part based on any previous medication trials you may have had,” I answered. “It’s also important to consider what else you may be taking currently, because drugs can interact which each other. If you have family members with OCD, we should look at what medications they responded to, since there seems to be a genetic component to response like there’s a genetic component to having OCD.”

“Well, I’ve never been treated for OCD before,” George said. “I don’t take any other meds, and I have no blood relatives with OCD to help guide us. So, it’s a clean slate!”

“Well, this leaves us with side effect profiles to help us decide,” I said. “The most likely side effect to this class of medications in a healthy young man would probably be sexual.”

“I cannot even hug my wife, let alone think of having sex,” George answered, smiling slightly at the irony. “Sexual side effects are simply not an issue for me right now.”

“Well, let’s start Zoloft, then,” I said. “It’s relatively clean and well tolerated. As with all SSRIs, though, when you’re taking them for OCD, you have to wait up to ten weeks for a response. The starting dose is usually 50 mg daily, and our target will be 100 to 200 mgs, if we’re not limited by side effects.”

"I feel fresh for a change"

Along with being his prescribing doctor, I also wanted to serve as George’s therapist, and, in many ways, George would have been the ideal candidate for therapy. A responsible and inquisitive young man, he seemed to have the youth and mental flexibility needed to make change possible and the creativity and faith it takes to see how the talking process can alter brain chemistry enough to effect this change. In the cognitive behavioral model, I imagined myself assigning him homework and him reporting back to me on his progress every week. I imagined focusing first on the basic tasks needed to meet some vital functions, such as food and hygiene. For instance, I would start by helping increase his comfort level with using utensils to eat normally again, while working on his fear of the showerhead. We could then move toward getting him back to work, perhaps part time initially, and maybe in an expanded cubicle. I would also try to help him gradually feel comfortable being intimate with his wife again: Maybe have him move back into the house at first but sleep in a different room, then in the same room but on the floor, then in the same bed, then have him hold her hand, then hug her, then....—unfortunately, though, it was impossible to get George to come in for the regular sessions needed for successful therapy. The length of time it took him to work through his anxiety enough to be able to make it to his appointments caused him to miss several sessions and made for an almost impossible therapy relationship.

On the other hand, George was very committed to taking his medication. So, instead of face-to-face weekly clinic meetings, I made the decision to treat him with the medication alone at first, and I monitored his progress and any side effects through phone contact every other week.

By our second phone contact after starting Zoloft (his fifth week on the medication), George’s voice over the phone sounded somehow more resonant and more self-assured.

“You sound clearer today, George,” I commented. “Are you feeling better?”

“I am,” George said. Then, sounding almost euphoric, he added: “But there’s also a technical reason for why I sound better.”

“A ‘technical’ reason?” I asked. “What is it?”

“Well, I’m calling from home, which helps,” he answered, “and I’m actually able to use the handset today! When I spoke with you before, I had to be on the speaker phone. I couldn’t tolerate the handset so close to my nose.”

“This is great, George,” I said. “Did you have to push yourself to use the handset for our phone call today? How much of a struggle was it?”

“It really wasn’t a struggle at all,” George answered. “I just didn’t think about it. It somehow didn’t occur to me today that the handset would hurt my nose. I only realized after dialing your number that, oh my God, I’m actually holding the phone! My only explanation is that the Zoloft must be doing its thing already...”

“I think you’re right,” I said. “I think we’re seeing an early response. That’s wonderful news that…”

“And I have more wonderful news for you,” George interrupted. “I also had a real shower this morning for the first time in a long while. I feel fresh for a change.”

“I’m sure that helps, too,” I said. “How about another basic function, eating? Are you still afraid of utensils and solid foods and can only drink fluids?”

“I certainly can’t handle pizza yet,” George answered. “The wedge thing still bothers me, so do knives and forks, but the good news on that front is that I can tolerate spoons now! For some reason, I’m more comfortable with round forms approaching my nose than pointy edges. That’s how I could eat a hamburger yesterday… A fat juicy one that tasted like the best burger I ever had!”
“I certainly can’t handle pizza yet,” George answered. “The wedge thing still bothers me, so do knives and forks, but the good news on that front is that I can tolerate spoons now!"

“It’s so nice to see you come out of this, George,” I said. “We’re only at week five, so we can still expect more improvement over the next couple of weeks. As I told you, many patients don’t get better until week ten or so.”

“Let’s up the dose anyway, Doc!” George said.

“Well, you’re tolerating 50 mg pretty well, so let’s go up to 100 mg and stay there for a while,” I concurred. “Call me at the same time in two weeks, and we’ll reassess.”

But before I could let George go, I had to enquire about his wife’s hoarding... We had decided that her behavior was contributing to my patient’s symptoms by increasing the ambient stress in the household, so I felt justified enquiring into it.

“Before you go,” I said, “can I ask you how your wife is doing with her hoarding these days? You said you moved back in, so I want to be optimistic and think that the house feels more hospitable to you. I realize it’s not my place to treat her, but…”

“Funny you should ask!” George interrupted. “You know, her mother who’s a neat freak, her father who’s a perfectionist in his own right and I who worry about hurting my nose,all have, for years, been telling her to clean the house up, but to no avail. Until, that is, your Dawn caught her in the act of stocking up! Well, I’m glad to report that your clerk’s intervention is working where nothing else ever has! Maybe out of embarrassment over what happened, my wife has, for the first time, decided to confront her problem. She has finally agreed to hire a professional declutterer that her mom recommended: a very methodical woman with a stern old nun quality to her who will not take no for an answer when my wife refuses to let her throw something—exactly what my wife needs! Well, ‘Mother Superior’ as we started calling her has already begun her journey into the heart of darkness that is our kitchen. The output so far, in case you’re wondering? Fifteen boxes of cooking magazines, yellowed with age, not extra virgin olive oil stains!”

Pizza: The Final Frontier

Exactly two weeks after our last phone contact, at the time of the scheduled call, instead of my phone ringing, I heard an assertive knock on my door. It was George, only much cleaner than at our last face-to-face meeting some two months before. His wife stood right next to him, her svelte frame curving slightly in George’s direction under pressure from his arm which he had wrapped tightly around her waist. Sight of the intimate-looking couple clearly indicated to me that the three-, two- or even one-foot rule was no longer in effect. And that George was probably not having sexual side effects!

“What a nice surprise!” I said, addressing George. “You look great.”

“Doesn’t he now?” his wife answered. “I have my husband back. He even drove us here!”

“And we have a gift for you,” George said, handing me a wedge-shaped present wrapped in aluminum foil and smelling of pepperoni.

“You brought me pizza?!” I asked, surprised and moved by this gesture.

“Yes,” George answered. “I bet no patient has ever given you pizza before!”

“No, no patient ever has,” I concurred. “This is a first, indeed. Thank you.”

“Well, pizza has been a recurring theme in our conversations,” George said, “and, in a way, it’s the best measure of how both silly and disabling my OCD was. All this makes it a fitting final thank you gift for you.”

“Well, I’m very touched, George,” I said. “Thank you again.”

“Wait!” his wife interjected, “It gets even better...”

“How much better can it get?” I asked, wondering what other pleasant surprises the couple had in store for me.

“It’s home-made!” George said, elated at the concept of a home-cooked meal.

“You’re able to use your stove again?!” I almost gasped as I addressed George’s wife.

“I can, indeed!” she said, “and we have our declutterer, or ‘Mother Superior,’ to thank for it! I just have to make sure I maintain now. ‘For each item that makes it into the sanctum of your home, an equal or larger item has to exit,’ she ceremoniously warned me at our last meeting.”

“In my experience, this is probably the best advice for hoarders and more likely to help than any medication or even therapy intervention,” I said. “Your approach of having someone do the throwing for you while you deal with the anxiety that this generates, and while you work on maintaining the result, is probably the way to go.” Then, turning toward George, I said, “What you have to maintain, and probably for a while, is your medication…”

“Oh, don’t worry, Doc,” George said. “I don’t plan to stop it anytime soon.” Later, watching George walk away from my office, his arm wrapped around his wife’s waist, all I could think of was how satisfying my cold pizza was going to be. With anticipation, I reached for the carefully wrapped wedge, slowly undoing the aluminum foil as I comfortably sat myself in the oversized patient chair in my office, turning it around so I could face the window. I raised my feet, resting them on the window sill, and prepared to take my fist bite. But as I was about to do so, an interesting scene unfolding in the parking lot outside my window caught my eye. I saw Dawn, all in black in observance of Good Friday, trying to catch up with George’s wife, carrying what looked like a high stack of magazines she had saved for her. I then saw George’s wife give her a big hug but decline the apparent gift, as suggested by Dawn energetically tossing the entire stack into the dumpster. The three then conversed briefly before George opened his car trunk, and all joined forces to pull a familiar-looking filing cabinet out of the trunk and throw it into the dumpster.

Pizza never tasted so good…


© University of California Press, 2008.
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Elias Aboujaoude Dr. Elias Aboujaoude is a psychiatrist at Stanford University School of Medicine, where he is Director of the Impulse Control Disorders Clinic. His work has been featured in The New York Times, The Wall Street Journal, The Los Angeles Times, on NBC, and elsewhere. His most recent book is Virtually You: The Dangerous Powers of the e-Personality.

CE credits: 1.5

Learning Objectives:

  • Describe symptoms of severe obsessive compulsive disorder (OCD)
  • Explain Aboujaoude's biopsychosocial approach to treating OCD
  • Critique the use of SSRI treatment for people with OCD

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here