Chapter 1. Patient: Jake

1.1 Introduction

Missouri State University

1.2 Presenting Complaint

Jake was on his way home from work on his 27^th birthday. It had been a difficult week at work and he was looking forward to a quiet evening with his wife, Ally, and their 2-year old daughter, Catherine. He pulled into the driveway and walked to the front door. As he opened the door, he was greeted by shouts of “Surprise!” from at least 30 familiar faces. It took several seconds, but he was finally able to muster a smile. He managed to make it through the next three hours of socializing, putting on a good show of enjoying himself, and being the “life of the party,” although he felt his anxiety growing with each passing minute. He couldn’t help but notice people touching his photos and small collection of rare books. He was patted on the back repeatedly and it seemed like someone was reaching out to shake his hand at every turn. As he showed the last guest out after 11:00 PM, Ally collapsed on the couch in exhaustion. Jake glanced around the room at the empty glasses, piles of trash, and half-eaten cake and other finger foods. Ally noticed his survey of the room and said, “Let’s just go to bed and worry about the clean up tomorrow.”

Jake had always been overly concerned about cleanliness, but he had been able to manage his life rather effectively around these concerns. He dismissed his wife’s complaints of the number of times he washed his hands by quoting health officials’ warnings that the best way to avoid the spread of illness is by frequent hand-washing. He insisted that he was simply using common sense, and Ally found it hard to disagree with his logic.

When his daughter was born, however, he found himself increasingly preoccupied by the idea of germs and contaminants. Catherine was so tiny; Jake began to think that there were dangerous microscopic particles everywhere that could make his daughter sick. While in the hospital, he noticed that there were antibacterial hand foam stations everywhere and this further fueled his feelings that they should be especially careful around their new infant. Although Jake had always been conscientious about washing his hands after using the restroom, petting an animal, handling food, or being outside, he started washing his hands even more frequently whenever the thought of germs passed through his mind. His hands became chafed and raw, but he was unable to decrease his hand-washing because he felt that he could so easily pass along a disease to his young daughter.

As Catherine grew into a toddler, Jake’s anxiety continued to worsen. Like all toddlers, Catherine loved to put anything she could find into her mouth. Each time Jake saw Catherine with an object in her mouth, he would quickly remove the item and scrub it with antibacterial cleanser. He began to clean the house every night, and he was unable to go to bed unless he had swept and mopped the kitchen floor, and vacuumed the rest of the house. He took antibacterial gel with him everywhere they went and he didn’t allow Catherine to ride in grocery carts or touch any items at the doctor’s office. He never changed Catherine’s diaper in a public restroom and he eventually began avoiding public restrooms altogether. He found himself spending more and more time thinking about Catherine (or himself) becoming sick or being exposed to germs. Jake’s mother was hospitalized for a brief period following minor surgery and he found himself unable to visit her in the hospital because of his fears. Of course, Catherine occasionally came down with a minor cold or stomach bug, and at these times, Jake doubled his efforts to maintain a “sterile” environment. To Ally’s dismay, Jake insisted that Catherine’s daycare center was not doing enough to protect against the spread of germs, and over a 6-month period, they switched daycare facilities three times.

Jake’s anxiety coupled with the amount of energy and time he began spending on cleaning made him irritable and generally exhausted. He and Ally found themselves arguing more than at any other point in their relationship. They had heard that having a child would likely increase the strain on their relationship, but instead of seeing an improvement as they adjusted to their lives with a child, things seemed to be getting worse. Ally decided to plan the surprise birthday party for Jake as a gesture of good will, believing that Jake could use a break and would enjoy getting together with his friends and family. But as she sat in the kitchen chair watching him scrub the floor, she felt overwhelmed by the situation and resolved that something would have to change.

1.3 Social/Family History

Jake grew up as the youngest of two children, and his older sister was now married with two children of her own. From an early age, Jake’s parents noticed that he did not enjoy having dirty hands. He never enjoyed playing in the dirt like other children, and his mother frequently described him as “fastidious.” Even as a young child, he never had to be reminded to bathe. When he was in junior high, he played on the football team for one season. During that season, he often bathed several times a day—before practice, after practice, and before going to bed. His parents never thought that there was a problem. In fact, they were somewhat proud of his cleanliness and often made comments about the poor habits of other boys Jake’s age.

Jake’s mother stayed at home until the children were old enough to go to school. He had limited exposure to other children until he attended kindergarten, only occasionally playing with the children of his mother’s friends. His mother enjoyed getting the children “dressed up” for church and other social events, and she often warned them not to get dirty. When Jake began school, his mother got a part-time job at the local school as a teacher’s aid. She tended to be somewhat of a worrier, particularly about her children’s health. She worried if they were in the sun too long or if they didn’t eat enough vegetables. At the first sign of illness, she would rush them to the doctor, always worried that the latest cold could worsen into pneumonia over night. She frequently cautioned the children about talking to strangers or getting out of her sight. She also worried about their grades, and would often stay up late at night to help them complete a school project to perfection. Even when her children became adults, she called frequently to check in on them and she would worry about their safety anytime they were on a trip. Both Jake and his sister would generally pacify her concerns, then say to each other, “You know Mom….”

Jake’s father was an attorney in a large firm. He worked long hours but always tried to make time on the weekends to spend with his children. He preferred outdoor activities and often planned trips for the family to go camping or fishing. He was somewhat embarrassed of Jake’s distaste for getting dirty, and occasionally commented that his son should “toughen up.” When Jake was 10 years old, his father took him on a father-son fishing trip with a local Boy Scout troop. His father caught the largest fish of the day, which prompted a request for a photo by the troop leader. His father gathered Jake to his side and tried to hand the fish to Jake for the photo. At first, Jake refused to take the fish, but his father insisted as other people began to take notice. After holding the fish, Jake had a panic attack when he realized there was nowhere to wash his hands. He felt disgusted by his hands and he held them awkwardly away from his body the whole drive home. The photo remains in a scrap book from his childhood and he finds it impossible to look at the photo without remembering his first panic attack.

Jake was fairly close to his sister although she was five years older and they did not have many things in common. Their personalities were often described as exact opposites. Although Jake preferred indoor quiet activities, his sister was described as a tomboy and, like their father, enjoyed all sorts of outdoor activities and sports. She particularly rebelled during her teenage years against what she perceived to be the over-protectiveness of their mother. Jake watched as his mother and sister frequently argued and struggled over issues of independence. He found these arguments extremely uncomfortable as he preferred to avoid conflict as much as possible.

Jake decided to attend college at the local state university to stay close to home. Despite being only two hours from home, he struggled with homesickness during his freshman year. He had a hard time meeting new people and he generally avoided large social events like fraternity parties or other organized campus events. He spent most of his weekends at home during his first year of college, which increased his feelings of depression each Sunday when he had to return to campus. The summer after his freshman year, he got a job at a local restaurant waiting tables where he met and became close to two other students. His new friendships helped make his sophomore year a bit easier and he soon found himself preferring to stay on campus rather than returning home for the weekends. His friends set him up on several dates, and although he had always found dating to be extremely uncomfortable in high school, he found himself having a good time on a date with a fellow student named Ally. He recognized that they had much in common, including their aversion to outdoor activities. They soon became inseparable and got engaged to be married during their senior year of college. His parents were ecstatic and quickly accepted Ally as a member of the family.

After graduating from college, Jake took his first job as an accountant for his father’s law firm back in his home town. He and Ally soon married and bought their first house. They were extremely happy and rarely had any major disagreements, making it even more difficult to understand their current situation and feelings of isolation from one another.

1.4 Multiple-Choice Questions

1.5 Treatment