Case Study of an Adolescent Boy with Obsessive Compulsive Disorder
Susan S. Woods, Ph. D.
Youth Services, Department of Psychiatry, University of Michigan
P.Q. is a boy from Ohio, thirteen years, nine months of age. He was admitted to
Children’s Psychiatric Hospital on an emergency basis on 28 March 1975. He had
been noted by both parents to have had increasing emotional difficulties since the
previous summer. Thes.e became worse during the week prior to .his admission. His
symptoms were primarily of an obsessive ritualistic nature involving repetitious
behavior, compulsive repetitive hand washing, and gradual elaboration of rituals
around bedtime. During the week before admission he was described as
“immobilized to the point that he cannot get out of bed”, spending the larger part of
his waking hours in rituals, and being generally unable to function. His primary
symptom on.admission was that he found members of his family and certain objects
“germy” and was therefore “unable to deal with them” His father believed the
problem began in mild form during the previous summer, following a visit to his
maternal grandmother. One incident during this visit involved a trip to a
convalescent hospital, with P. subsequently being concerned and upset by sick or
damaged people, He started then by being unable to wear certain clothing because
“it was contaminated.” As time went by, areas of the house became off-limits to
him. Similarly, he felt that one of his stepbrothers “was unclean” (germy), a situation
that soon extended to all the members of the family. They were all felt to be
contaminated, with the exception of his father. His stepmother however felt that P.
had been having difficulty for a substantially longer period of time. in fact, it seems
that his symptoms had been apparent to some degree for several years, having
started some months after his mother’s death. The stepmother described the
appearance of what proved to be a long series of “strange habits” about five years
earlier during the summer. For instance, he began hopping every so many steps.
That was followed by repetitive smelling of the table and the walls, eye-blinking,
head-jerking and pausing with hands in
148 Obsessional Neuroses
praying position before entering rooms. Simultaneously, his peer relationships
deteriorated and for a year or so now his brothers and stepbrothers had been teasing him
about this behavior. More recently they had developed a strong hatred of him. Further, his
symptoms had been increasing very noticeably for the five months previous to the referral
to this institution. Thus, shortly before this happened, the Q.’s received a call from P.’s
school one evening stating that P, had been trying to get through the door and out of his
classroom for a period of over two hours. This Fall P. was referred for evaluation
somewhere else, and therapy was recommended and begun on a weekly basis with a
psychologist affiliated with the Department of Pediatrics of Ohio State University.
Three weeks prior to his admission here P. reported that he had “lost the key” to his
mental processes. His parents were uncertain as to the meaning of this and could think of
no precipitating events either within the family or with P.’s personal life.
Dr. and Mrs. Q. (P.’s stepmother) were eager for adMission at Children’s Psychiatric
Hospital and it has subsequently become obvious that they are relieved by his absence and
reluctant to have him rejoin the family unit. The Q.’s are involved in marital therapy at the
present time in Ohio, the marriage having become very rocky as a result of the stresses of
P.’s psychopathology.
P. expresSed concern upon admission that there would be retarded or weird children at
C.P.H. He was relieved after seeing the place because he saw no “weirdos” and found the
hospital to look “very clean.”
From the beginning P. has had a generally positive attitude toward admission, seeing it
as “the only way to get rid of my problem.” He can be expected at times to resent the
family’s splitting him off or scapegoating him as the one with the problems,
Description Of The Child
P. is a small, thin adolescent who has been described as an, Oliver Twist type. Indeed
he often walks around with a haunted expression, hair falling into his eyes, shirttail
hanging out, holes in.
hiS pants, etc.
Clinical Examples 149
He hardly gives the impression of a. compulsive personality, judging from his unkempt
appearance. There have been occasions when he takes care as to how he looks. These
times usually accompany a trip home or an outing with his family where he has enjoyed
himself.
Upon admission most of his clothes were rather old and shabby. He explained that he
had plenty of “cool” clothes but that they became germy after his trip to his grandmother’s
home. Finally P. was having to use safety pins to hold his pants together, wore no socks
and had large holes in his sneakers (the only shoes he would wear). He was upset, crying
when the staff finally felt that his father should be approached to ask him to buy P. some
new clothes. Dr. Q. was angry and somewhat embarrassed, explaining that P. had many
new articles of clothing including new shoes but to his and the family’s endless frustration
P. wouldn’t wear them. Dr. Q. finally bought P. some trousers and socks and a new pair of
sneakers. P. was amazed and overjoyed that his father had bothered to buy him clothes
and had spent so much money on him.
Generally P.’s behavior in the various areas of the milieu were consistent. Upon arrival
everyone was concerned about his need for repetition; for example, on his first morning at
breakfast he felt a need to throw away and retrieve his milk carton numerous times,
stating he had to “think right.” Showers and bedtime preparation were another source of
concern, often consuming the better part of the evening. Any attempt to interrupt the
rituals or hurry P. were met by his whining and crying that people didn’t understand him
or his problem. A staff member commented that he had rarely seen such pain in another
human being.
Group activities in the school and with his ward group also became problematic.
Briarwood Mall (a large, new shopping center near the hospital) for example was germy
because it was so “modern and weird.” The arboretum later became off-limits because it
bordered a cemetery. Most recently anything related to magic i.e., the color black,
sparkles, glitters, psychodelic posters, record album covers, or book covers, movies about
ghosts or witches, have produced enormous fear and given P. difficulties when trying to
“think right.”
Classroom behavior has been good and appropriate for the most part with occasional
problems with some students. After Passover P.
150 Obsessional Neuroses
developed an intense interest in Judaism, making a Star of David in Occupational
Therapy and wearing it around his neck. For a time another class member drew swastikas
on the blackboard, During TB’s vacation this rivalry became so intense that P. spent most
of his class time in the hall voluntarily and began to carry a transitional object, a ceramic
bunny, which he had made in Occupational Therapy. In P.’s Occupational Therapy group
he is the oldest member the other children ranging from ages eight to ten. The group has
changed from five to three members since P. was admitted. It is reported that P.’s
intelligence, gross and fine motor skills and creativity all appear to be age appropriate or
higher. Initially P. did not accomplish much, He spent much time•perfecting his projects.
The planning and organizational aspects of. the project were difficult for P. For example,
he wanted to make a Star of David and it was suggested to him to bend the wire to the
desired angles. He rejected this suggestion and became involved in finding a mathematical
formula to approach the problem. P. spent the remainder of the hour, approximately thirty
minutes, attempting to devise a mathematical formula. He became anxious and frustrated
with being unable to solve the problem. The next day however he was able to enter the
shop and just bend the wire to the desired angle, This seems to be P.’s approach to
problems—many times he must try to find a means of ordering or perfecting a project
before he is able to work at a more appropriate pace.
Initially P. remained apart from the group. He appeared very anxious and withdrawn.
He spoke only when addressed and interacted minimally with other group memberi. As he
became more comfortable with the others he began to interact more. He appeared to be
more at ease and seemed to enjoy the group. It appears that this group of younger children
allows him to regress to behavior inappropriate for his age i.e., making animal noises etc.
P. approached his occupational therapist on several occasions, asking about her
family and her. practice of Judaism. These conversations were precipitated by her
announcement to the group that she was taking several days off for Passover. Of late there
have been no questions concerning Judaism.
P.’s concern about a family have been brought up on a number of occasions in the
group. Once he made a family of ceramic rabbits and in a childlike manner stated “a
family—isn’t that cute?”
Clinical Examples 151
Generally P. relates N,vell to ward staff and peers and is not considered a behavior
problem.
P,’s relationship to two of his ward staff have been significant. K. and J. became
vehicles for P.’s lingering phallic-oedipal conflicts, and were loved objects. P.
frequently told K. that he wanted J. to tuck him in at night, He became anxious when
he discovered his liking for J. was greater than that for K., and he found it difficult to
understand that both could be loved .in different ways at the same time.
After K. left, P.’s liking for J. as a maternal object developed into a “crush.” He
discussed her constantly in therapy, voicing his anger after learning she was married
but seeing how futile his desires were because “she is a lot older than me,” He wanted
to be “mature” to win her attention.
During J.’s vacation P. decided that she was germy since she flew through the
“Bermuda Triangle.” Their relationship was over as far as P. was concerned. P. also
knew thatbpon J.’s return she would become a primary staff and thus have relatively
little to do with him, He attempted to leave her before she left him.
Family Background and Personal History
Mother: P.’s mother, H.Q., is deceased. A slim, dark-haired woman, she married P.’s
father in 1952, and suffered a reactive depression upon leaving her mother. After the
birth of each child except P. she suffered post-partum depressions. At each of these
times Mrs. Q.’s mother would come to aid her daughter. Mrs. Q. felt her mother could
“magically” help her to improve. Mrs. Q.’s mother was described in one report as an
“aggressive unloving woman. Mrs. Q. seemed to thrive on her criticism.”
Mrs. Q. was admitted to N,P,1. on four separate occasions for severe anxiety and
depression, She was expecting P. during her fourth hospitalization. This is a part of
the report of her psychiatrist:
If I were to speculate on some of the psychodynamics, I feel that unconsciously
Mrs. Q, felt she won the oedipal struggle against her mother. The patient’s mother is
a very hostile and aggressive woman who constantly yells and degrades the patient.
Mrs. Q. felt that she
152 Obsessional Neuroses
must have done something wrong and therefore felt guilty. We can see that since
childhood and especially since the patient has been married any symbolic libidinal or
aggressive energy (such as buying a house, having children, etc.) makes the patient
very anxious and depressed as a reaction to her guilt and she seeks the reassurance and
acceptance of her mother via the mother’s hostile and degrading comments. The patient
described a very hostile, symbiotic, sadomasochistic relationship that she had with her
mother. She felt she always had to go to her mother who in turn would berate and
belittle her, in order that Mrs, Q. should feel that she was still loved and accepted by
her mother.
The patient went on to describe that she would even provoke situations as a a child
which would ’cause her mother to yell at her and this would reassure the patient that
her mother still “cared for her,” Mrs. Q.’s mother exhibited both overtly hostile and
passive aggressive attitudes toward the child and the only way that Mrs. Q. could
retaliate was in her own passive-aggressive way by dawdling or doing things just the
opposite from the way that her mother wished.
During her hospitalization Mrs. Q. expressed suicidal thoughts and fears of harming
her children.
During her last pregnancy (P.) Mrs. Q. was told by her mother that she should never
have any more children because she couldn’t care for the ones she already had.
. Mrs. Q. went to her father as a child for emotional support and felt he loved her more
than he did his wife.
Mrs. Q. had a sister whom she viewed as “the bad daughter” and felt she had to be “the
good daughter.” Mrs. Q.’s sister has also been hospitalized for depression.
Mrs. Q. was always involved in aggressive battles throughout her life. In college she
and her husband-to-be were in the. same class. She was the valedictorian and he the
salutatorian. She went on to obtain a master’s in chemistry. On her third admission to the
psychiatric ward she talked about her husband’s attitude, stating he felt her
hospitalization was not necessary and that she was taking the easy way out.
Mrs. Q. was tremendously conflicted about motherhood. She felt
Clinical Examples 153
One can assume that during this period there was little emotional energy for nurturing
the young children in. the home.
she was still a child and wanted to be a child, Mother’s Day was apparently an enormous
symbol for her. She was admitted once just before Mother’s Day complaining that she
“couldn’t handle her life.” On another admission she became “preoccupied”, staring into
space and complaining of being frightened after a conversation among the patients
regarding Mother’s Day.
On Mother’s Day 1970 Mrs. Q. took an overdose of barbiturates and died two days
later.
Father: R.Q. is a forty-five-year-old physician somewhere in the State of Ohio. He and
his wife were both originally from Boston where they met and married while attending
.
the university.
The couple moved several times early in the marriage, to Arizona, New Mexico, and
finally to Detroit, where Dr. Q. completed his residency in medicine..
Dr. Q. was seen twice on Mrs. Q.’s first admission in 1960. He was quite anxious and
seemed uncomfortable. He also seemed depressed and agitated, stating that he was unable
to concentrate on his work. He intellectualized -a great’ deal, saying that he thought his
reaction was a typical one to a depressed wife. He added that he was quite ldnely and did
not like being away from his wife. He felt that if he could be with her he could be
supportive of her as he had been in the past. Dr. Q. felt that the only person he could
accept reassurance from was a doctor who was treating his wife. Dr. T. (wife’s therapist)
called Dr. Q. daily to support him and tell him of his wife’s progress. Dr. Q.. felt that this
was not very effective in easing his anxiety but that it was all he had to hold onto. Dr. Q.
also stated that when his wife was depressed he felt depressed too and when she felt better
he felt better. The report of the treating psychiatrist goes as follows:
The highly interdependent nature of the relationship described above was confirmed
by Dr. Q.’s statements to me that he thinks his own willingness to be constantly
available to his wife tended to feed her dependency on him and that the two of them
seemed locked ,together in the ups and downs of this depressions
154 Obsessional Neuroses
Dr. Q. placed a great deal of emphasis on the kind or quality of therapy his wife
might be receiving. He was concerned that she be treated by a staff psychiatrist rather
than a resident, He resented seeing a social worker about-his adjustment to his wife’s
illness. Remnants of this are still visible in Dr. Q.’s wondering why neither he nor P.
saw psychiatrists at C.P.H. He asked about his son’s therapist’s credentials. P. too
shares these feelings, frequently asking what a social worker is, what M. S. W. stands
for, and on one occasion commenting that he believed his therapist could probably
help him as well as a senior psychiatrist. Dr. Q. is a rigid, obsessive-compulsive
character himself. This became evident in his endless ramblings from subject to
subject during the time of history taking. It was impossible for him to get through
recounting a simple event without trying also to include every minute detail of his
association to the event. He feels that his memory is poor and confused and he never
ends satisfied that he has really told the story “right.” He described himself as having a
“stubborn streak.”
Stepmother: This is the report of the parent’s therapist: During the summer
following P.’s mother’s death, – Dr. Q. arranged for a housekeeper, now Mrs. S. Q , to
come into the home. She had just divorced her first husband and was supporting three
sons from her first marriage. Her sons were away at camp during the first few weeks
after she came to the job, and she recalls that P. was the first of the Q. boys to make
friends with her, She had a great deal of time to devote to P. during these weeks and it
was only when her own children returned that she and Dr. Q. began going together. P.
then began to distance himself from her, When the marriage became imminent the
following fall, P.’s siblings reacted quite angrily and P.’s more quiet reaction seemed to
go unnoticed. Following the marriage P. became more and more withdrawn. He
especially had difficulty accepting her youngest son, who is described as being quite
different from P., i.e., rough and aggressive.
The family moved in 1971 to Toledo, where Dr. Q, practices. P.’s siblings were very
unhappy about the move and again their more obvious behavior pushed P.’s into the
background. One had problems in school and another became very depressed. O. cried
frequently, withdrew, developed colitis. At his school’s suggestion a began
Clinical Examples 155
psychiatric treatment of problems described as “similar to P.’s.” This treatment has
been ongoing to the present time. Mrs. Q. described the relationship between herself
and 0. at that time as very poor. 0. is described as being much like his mother, the first
Mrs. Q., bright and close to his dad. P. was closest to 0. of all his sibs and would often
try to emulate him (this relationship has now dete’riorated to the point that the boys
rarely speak). As relationships became more strained throughout this period it was
more and more difficult for Dr. and Mrs. Q. to communicate with each other about the
children. In 1971 the Q.’s daughter, B., was born. According to both parents her birth
was greeted quite positively by the older children. Currently B. is the only sibling
within the family with whom P. is willing to interact on his home passes and she is the
only child who inquires when he is coming home.
Developmental history: P.’s mother was hospitalized at N,13
.1, for the third and
fourth time during her pregnancy with P., for symptoms . of anxiety and depression.
She was admitted and discharged in May of 1961 and readmitted in June of 1961. Just
before Mother’s Day in 1961 she phoned her psychiatrist and described suicidal
thoughts. This pregnancy was obviously a strain for Mrs. Q. and increased her fears of
inadequacy about motherhood.
P. Was born two weeks early as was the pattern of all Mrs. Q.’s children. Labor
lasted one hour and ten minutes. P. was a six-pound, eleven-ounce infant delivered
under caudal, anesthesia. Mrs. Q. recovered quickly with no complications for either
mother or son. P. was breast-fed.
from birth and follow-up interviews with Mrs. Q. at
N. P.1. found she experienced this as pleasant and took pride in the care of her infant.
P. was described as a peaceful sleeper and he slept completely throughout the night
very early .on.
P. developed atopic dermatitis which Dr. Q. described as a red rash occurring in the
creases of his body. He said that P. did not seem to be uncomfortable with this. For
several weeks P. was put on a special diet in an attempt to determine the source of his
allergy. Dr. Q. again recalls no difficulty or food refusal during this time and the
special diet was finally stopped as the pediatrician seemed to feel it was not helping
diagnostically.
Dr. Q. says that he recalls very few specifics regarding the P.’s age at
156 Obsessional Neuroses
the various early developmental milestones, However he feels that P. accomplished most
things just a bit earlier than his two older brothers. For example, he believes his son held
his head up quite early, was responsive to external stimuli and began picking up. and
playing with crib toys at a very early age. Although he cannot recall when P. was weaned
it seems that it was fairly early and he does recall that by the age of one P. was feeding
himself, While recounting this history Dr, Q. often interjected that he recalled his wife
being troubled and anxious and on’many occasions emotionally tied up within herself. He
says that even though Mrs. Q. took good physical care of the children he feels now that
they probably were emotionally, neglected.
P. toilet trained himself at age two and half “almost overnight,” Dr. Q. does not recall
the development of P.’s speech but does remember that once he began talking he talked
almost incessantly. P, rarely played with children his own age, preferring to spend his
time with adults or playing with his older brothers,. When P. went to
kindergarten at age five, Dr. Q. recalls him telling long stories about what had happened
at the end of the day. He also recalls himself and P.’s mother being amused at what a long
story P. could make out of a very small event. The father remembers no difficulty in
separation from Mrs. Q. when P. began kindergarten.
The following information was learned from the second Mrs. Q.: Mrs. Q. said that by
the time she met P, at age seven almost all of his interests and interpersonal relationships
centered on adults. He struck her as being a very dependent but cooperative child. She
even described Him as “a model child.” She recalls that he always liked to have his things
in order although he was not really fastidious. It was always quite difficult for him to get
off to school•in the mornings as it was quite a chore to get through all of his routines. By
the age of twelve P,’s compulsive mannerisms and rituals had become a point of great
contention between him and his siblings. Mrs. Q. remembers that approximately ten
months prior to P.’s hospitalization his brothers began to noticeably withdraw from him
and make fun of him. Before long all of the siblings seemed to be angry with P. It was
also during this year, fall of 1973, that P,’s grandfather died. Although the parents would
not characterize P.’s relationship with his grandfather as a close • one, he did visit with the
grandparents annually and seemed to greatly
Clinical Examples 157
enjoy walking downtown with his retired grandfather and being a part of the
interaction with all of his grandfather’s “old cronies.” When the grandfather died the
maternal grandmother sent • the grandfather’s personal watch to O. rather than to P.
Dr. Q. •stated somewhat resentfully that this was typiCal of his former mother-in-law,
that is, to be more interested in a tradition of giving a gift to the oldest grandchild
rather than giving it to the one who had been closest to her husband.
The summer prior to this hospitalization all three of the older Q. boys were invited
to visit the grandmother. True to form, •only P. accepted the invitation and remained
with the grandmother for about three weeks. .Upon his return from this trip Mrs. Q.
states that she began really pushing for help for P.
Possibly Significant Environmental Circumstances
Timing of the Referral: The timing of the referral seems to have coincided with the
severe manifestation of the obseSsive compulsive neurosis, however the problem in
earlier more manageable stages seems to have been present for some time longer.
Since P. often has difficulties determining when events happened and how long he has
experienced difficulty, both the extent and duration of his symptoms are still
unknown, He believes, however, in agreement with his father, that the major
disturbance began last Summer after a visit to his maternal grandmother in
Connecticut.
This visit was an event for P. each year.. He was the only grandchild who enjoyed
these trips to Connecticut and last summer he went alone. This was P.’s first trip to his
grandmother’s after his grandfather had died of a heart ‘attack a year before. P. had felt
very close to his grandfather, more than to his grandmother whom he described as
“mean and al vays telling me what to do.” It is significant that P. was concerned to
maintain the ties with his mother’s parents. P. is also the only child who wants to
practice Judaism, something which is frowned upon by the rest of the family but
which was highly regarded by P.’s mother, It seems P. is trying very hard to keep his
mother alive in a sense by holding onto the significant objects in her life.
Causation of the Disturbance: Four areas can be delineated as causally significant:
1.158 ObsessionalNeuroses
2. The mother’s suicide. H.Q.’s suicide is a pivotal issue in P.’s psycho-
pathology. He failed to mourn her loss, fearing that to express his feelings would be
against his father’s wishes. He is now engaged in the draining process of keeping
her alive (which he believes his father, a physician, failed to do) by holding onto
her traditions. as previously mentioned, Significantly P.’s stepmother is neither
Jewish nor religious and he resents the fact that the family has given up all Jewish
traditions. A particular blow came on P.’s thirteenth birthday when his father
offered him money and said that would take the place of being bar rnitzvahed. P.
felt this cheapened what is to him an important event – symbolizing his “becoming a
man.”.
In therapy P. had tremendous difficulty remembering his mother or any experiences
they shared. He vividly remembered, however, the day she died and described it several
times. The most significant aspects seem to have been when his mother was taken to the
ambulance. She opened her eyes for a second and looked at P. He also remembered how
angry his father became when P. told a neighbor that his mother was
1. The father’s remarriage. P. was initiallS
, warm and accepting of the present
Mrs. Q. before she married his father. After the marriage their relationship
deteriorated, She describes P. as acting like “a twoyearTold.”
The division between old family and new has continued to worsen. P. cannot accept
his stepbrothers especially now that they “have changed.” What this change entails
is their move into adolescence with a concommitant increase in foul language, rough
behavior and less care in personal hygiene.
1. The father-son relationship, ,In one session, P. described his relationship
with his father as being like the song, “Little Boy Blue and the Man in the Moon,”
where a little boy all through his life asks for time with his father but the father is
always too busy. Later the father retires and wants to be with his son but the son by
that time has his own life and says he’s too busy to see his father.
P. has tremendous difficulty expressing his feelings to his dad. He perceives him as
all-knowing and all-powerful but very inaccessible. P. is visibly elated by the grief times
he spends with his father but it seems he does not convey this when he is actually with
his father. Dr. Q. describes P.’s behavior when they are together as passive, bored and
Clinical Examples 159
angry toward sibs. When P. and his father are together they talk about science. P becomes
anxious when he runs out of things to say to his dad. (This happens in therapy too.) He
needs a mental script Well planned out before he feels comfortable.
Dr. Q. is a rigid, authoritarian person who seems to have provided an atmosphere
where P.’s feelings could not be exhibited. Childish emotions of glee or anger were
scorned. To show them meant to risk rejection and withdrawal of IOW. P. learned from an
early age to control himself, to measure up, to be adult in order to obtain parental
acceptance.
4. Adolescence. P. wants to be a man but fears outdoing his dad. He has tried to avoid
any competition with him so far, Now he is beginning to see that his father may have
problems but at the same time he has decided that all doctors are perfect and able to
overcome all difficulties.
Physically P. is small and underdeveloped. This concerns him because he wants to
be strong so he can “beat people” in games and frequently taLks of beating people up
when they upset him.
He likes to be with younger children so he can be superior but resents their childish
behavior.
Adolescence has also raised the unresolved oedipal issues which are central to P.’s
difficulties.
Possibly Favorable Influences: P. is a bright, interesting, and interested child. He
relates well to peers and staff and relates warmly to particular staff, mainly women. He is
an attractive . child and is frequently described as cute.
His interests are varied and socially he is quite sophisticated.
His parents though severely troubled themselves have engaged in marital counseling. It
seems the.
family is trying hard to get back on its feet. What place P. will have upon
reuniting with the family is hard to guess. P. has tremendous motivation in thearapy. He
is insightful and frequently makes his own interpretations which are often accurate.
160 Obsessional Neuroses
Assessments of Development
Drive Development
1, Libido
a, Phase.
development
P. is developmentally a preadolescent. He has brodd interests in art, science, music,
especially popular music, i.e., John Denver and the Beatles. He has good relationships
with peers and adults but has difficulty when peers exhibit aggression which could be a
physical threat, or when staff is authoritarian. He expresses dislike for the rules that are
imposed and would like to liVe in the wilderness all alone, free from society’s restrictions.
Oral Phase: The oral remnants are seen in P.’s occasional sucking motions and sounds
at the end of therapy sessions, in. his dislike of young children, and in the oral-sadistic
rituals around food (putting food into his mouth and then taking it out, difficulty entering
the dining room). He also has difficulty swallowing (he must think right) and he cannot
eat, for example, at the Detroit Zoo because it is surrounded by cemeteries. (Notice the
anal-sadistic connotations of this.)
Anal phase: P. strives to control his anal-sadistic impulses and fantasies with rituals and
obsessive thoughts. One such fantasy he described as “the pool of imagination, a horrible,
dirty, black gooey place that wants to pull me into it. Sometimes my eyes fall in.”
Whenever he thinks of this he must repeat what he has been doing to avoid anxiety.
Unconsciously he is, as his stepmother described, “a two year .old” expressing
ambivalence, sado-maSochism, tendencies toward stubbornness and rebelliousness.
Rdaction formation is P.’s main defense. The move toward adolescence has undoubtedly
contributed heavily to this pattern,
Phallic-oedipal: P. describes himself as “curious George” and expresses an interest in
sex. He developed a “crush” on one of his female child-care-workers but he found this
relationship odd when in therapy he saw her as both girlfriend and mother and said “but
you can’t have sex with your mother,”
Generally P. idealizes adults, particularly men but fears his own adulthood because it
might lead him to be better than his dad,
Clinical Examples 161
P. is just beginning the adolescent phase and has not reached phase dominance. He is
expressing an interest in sex though he is having difficulty with feelings of
embarrassment. He has recently begun to discuss some of his sexual feelings in therapy.
Often they have a decided oedipal component. Recently too he has shown some interest in
a twelve-year-old girl in his class and behaved quite appropriately with her, as opposed to
infantile behavior with another girl.
b. Libido distribution
i. Cathexis of self,
Primary narcissism: P. does not have difficulty in primary narcissism. Secondary
narcissism: P. considers himself to be intelligent with a good sense of humor, however
physically his estimation of himself goes way down.. He fears he is
.
inadequate, not
strong, uncoordinated and thus unable to successfully compete in athletics or engage in
physical fighting with peers. To some degree his older brother’s move into adolescence
was threatening to P. and may be responsible for the symptom formation to some extent.
He believes he never got enough love or attention from his father. He desperately tries
to prove himself to his dad but is always disappointed to learn how his dad “didn’t notice”
how happy he was to be with him. His chief complaint now is that his dad is strong and
capable, so why shouldn’t he let P. come home on weekends?
P. has developed a split between his natural mother as a good mother and his
stepmother as the bad mother. He can no longer have needs satisfied by his real mother
and he fears rejection by 1-
tisstepmother.
P. is highly invested in his memories and fantasies of his mother. He recalls that when
he was about four he and his mother had mumps. The whole family was concerned about
them. P. became deaf in one ear because of his illness. He is identifying with his mother
now and says he is a replica of her because he is hospitalized “for being crazy,” He
fequently talks of suicide when difficult material is raised in therapy. One day he even
said that he tried to commit suicide by cutting his wrist with a comb but it only made
white scratches. He said that he wasn’t interested in really killing himself, he just
wondered what other people would think if he did.
His goal now is to be like his father. He wants to be a doctor (a
162 Obsessional Neuroses
neurologist) so he can learn how the brain works. He depends on his father to supply
him with the guidelines so he will not fail. His father told him “a healthy body is a
healthy mind,” after his admission to C. P. H. P. immediately began an exercising
.program. He runs contests with himself. He wants to set records, which mean
winning to him, for instance brushing his teeth every night for a year. His favorite
hero is Einstein.
His relationships with other people are warm and accepting. However, once a strong
relationship develops and any hint of rejection is present he rejects before he can be
rejected. When he learned K,D. was leaving, K. became “germy.” When P,’s primary
staff was taken away from him and assigned to another child, she became germy. He
now realizes what this behaVior means and says that if he likes someone a lot they
can’t be germy for very long,
P. is dependent on external objects to regulate his self-esteem. However he is
capable of independent action and thought, the only motivation seeming to be self-
satisfaction. He has difficulty accepting praise, usually laughing or saying “sure, sure,”
but it is obvious that he likes it an agrees with it,
ii. Cathexis of objects
P. has the capacity to form and maintain relationships with peers and adults. It often
seems that the peers who become objects of competition are rejected, for example,
brothers, and a friend from Ann Arbor whom he had not seen in several years. P. was
excited about seeing this friend again but this fifteen-year-old had matured and grown
quite .a lot in the meantime. P. felt weak and small by comparison and has not
contacted his friend since. Very recently, he has expressed interest in seeing him
again. –
P, attempts to control adults with his problems. “1. can’t do that because of my
problem” This has led to concern on staffs part as to how much to push or give in to
“the problem.” At first P. would take over an hour for an evening shower, and bedtime
rituals were an agony for all involved in his care.
P.’s closest and most enjoyable relationships have been with female peers or staff.
He was very proud when a young girl from fourth level showed some interest in him
(gave him a yo-yo and sat next to him at a movie) but was somewhat embarrassed
since she was “too young” for him, His relationship with J, (female staff) has been
primarily positive
Clinical Examples 163
but very much tied to oedipal conflicts. Recently he has shown some interest in a twelve-
year-old girl in his class and feels she is “the right age for him” “not half as old or twice as
old” as with his other two female interests. P.’s relationship with K.D. was good but he
felt K. was not strong enough at first. Later he felt that K. was one of the few people who
could “really understand me.” Strong authoritarian men are seen as “fair” by P. though he
resents their orders.
2. Aggression
The expression of aggressive impulses has been one of P.’s major areas of conflicts.
Until quite recently he has denied angry feelings, particularly those addressed toward his
father. However a great deal of aggressive energy is bound up in his rituals and obsessive
thinking, which ward off his expressed fantasy of hitting people over the head with coke
bottles (particularly vacationing staff) or sending authoritarian staff through a bologna
slicer! For example, if he thinks of putting someone through a bologna slicer he must put
them back through to make them all right again (thinking right).
Aggression is also seen in his tremendous need to control the environment. Angry
crying spells and stubborn refusals often accompany change of plans for any
unanticipated event,
P.’s aggression not only inflicts pain on the environment but is most often more painful
to him. He feels trernend ously *anxious and guilty over his aggressive thought, and the
rituals also serve as punishment for his self-peiceived “badness.”
Ego and Superego Development
a. Ego apparatus: his ego apparatuses are intact.
b. Ego functions:
Affected by and interfered with by his psychopathology, he is nevertheless clearly a
highly intelligent child with reading skills, mathematical reasoning, and mathematical
fundamental skills above his chronological age.
a. Ego reactions to danger situations:
P.’s fears are lodged in the external world in the form of fear of loss of objects. The id
impulses are also feared characteristically because they may force him to become out of
control and do things (show anger
164 Obsessional Neuroses
or aggression) which would be severely punishable by his superego. d. Defensive system:
Denial: P.’s obsessional substitutions utilize magic and rituals and are a defense which
fosters power and strength in a world where he feels helpless and weak.
Rationalization: Since P. fears the “weakness” he thinks is implied in tender feelings,
he recently denied his anger and sorrow at the vacation of an important P . C. W by
claiming she had a “right” to the vacation and he should not.feel bad because it was her
“right” to go away.
Intellectualization: Enormous energy is spent in .holding back feelings by
intellectualization. P. has such an explosive need to love and hate (punish) his father for
rejecting him and/ or his mother but the only way he can deal with his father is through
scientific discussion, He feels anxious if he is with his father without some specific
intellectual topic to discuss, Unfortunately his father relates to P. in the same way.
Reaction-formation: Classic obsessive concerns for cleanliness, order, being good, are
perceived as knowing the rules and following them, according to P.’s pattern.
Paradoxically, he expresses a great longing to live in the wilderness free from human rules
and regulations and living exactly the way he please.
P. also belches frequently and then immediately bows his head and whispers “excuse
me please” sometimes three or four tlines in a row.
Doing and undoing: P. uses this defense in many areas but perhaps the most suggestive
is his need to read a line and then “unread” it, For example, read backwards, This may
indicate his need to know or his fear of knowing or the ramifications of the quest for
knowledge, related to the suppression of information regarding his mother and her death.
Extensive use of displacement, isolation of affect and content are noticeable,
e. Secondary interference of defense activity with ego achievements:
P.’s defensive system keeps him vulnerable to the fears he experiences in every new
situation. It prevents him from learning by experience. He is so involved in creating
reasons not to be somewhere or not to express feelings that he is virtually paralyzed by a
system where there is no relief and where every day poses a threht of defeat, f, Affective
states and responses:
P. is capable of expressing a wide range of affective responses. He is
Clinical Examples 165 •
a sensitive child and the potential loss of loved objects evokes anger, hate and guilt. It is
only recently and only to certain staff members that P, is able to tell how he feels. Sad
affects are usually masked by imitation crying or sarcasm,
P.’s self-esteem is low and this is particularly evident when gifts or praise are given to
him, He says he never felt anyone gave him anything because they loved him but only
because they wanted to “satisfy him,” The only area where he acknowledges success and
accepts praise is with his intelligence. Though P. is capable of affective responses and
often displays them appropriately, his behavior becomes inappropriate when he is moved
–
by a person important to him
P. is still somewhat egocentric and narcissistic. For example, he feels everyone
thinks the way he does, and should, therefore, understand his problem, He is
terrified of the anger of others especially – if it might result in physical confrontation,
Authoritarian people are disliked and criticized even when he believes their rules are fair
and right. He whimpers and cries and impotently feigns rage when forced to do something
he doesn’t want to do.. Often his responses can be described as overreaction. Usually the
anger or hurt is not long-lasting though he tends to hold a grudge against those who have
caused him to display negative affects.
Superego Development
a. Superego:
P.’s superego is overly developed, punitive, nonpleasure-giving, unrelenting, and
constricting, The superego introjects which contribute to this pattern stem from the anal
and phallic-oedipal stage based primarily on his overly restrictive father and his perhaps
uninvolved, distant or permissively ambivalent mother. He felt he had to be good to win
parental approval. “Bad behavior” meant risking parental rejection, The id has a need to
discharge its persistent drive and the ego is left as the battleground for the two opposing
sides. Normal childish feelings of gratitude, happiness, excited joy, sorrow, or pain and
anger came to be viewed as weaknesses to be avoided, denied or isolated, so that he could
be the good, calm, placid child he felt his parents desired.
a. Superego ideals:
166 Obsessional Neuroses
The most obvious and most frequently mentioned superego ideal stems from his
identification with the aggressor (father) and his wish to outdo or overcome his father.
He wants to be a brain surgeon who will find the definitive cure for cancer and be the
first to perform successfully brain and spinal-cord transplants. Not only will he be the
first but he will be nationally famous and admired.
a. Other types of ideal formation:
Certainly his desire to become a physician is an appropriate ego ideal as his
intelligence and latent personality strengths suggest. It is clear also that even as an ego
ideal there is the apparenridentification with the aggressor” and his own self-desribed
“little-boy-blue” phenomenon.
a. Development of the total personality:
In general P. has not reached age-appropriate development and may be found in the
preadolescent stage. His over-all development suggests an initial ease in the
developmental milestones without disruption.
There is no noted separation-anxiety in Anna Freud sense of the word, and since he
was the youngest child in the original family there was no conflict there. His illness,
mumps, along with his mother at age four, served to increase his identification with
her and left a permanent reminder of their shared experience.
P. did not want to attend nursery school (possibly a fear of • separation). He recalls
(or has been told) that he stubbornly refused to go and would not dress himself or
allow himself to be dressed for the occasion. This is reminiscent of his present
aggressive behavior around bedtime rituals. Ile states with pride “and 1 never did go to
nursery school.”
School itself was not a problem and both parents recall delight in observing P.’s
reaction to it. We can only speculate that the kind of disturbance observed -now, with
its anal-sadistic qualities, indicates difficulties stemming from the anal phase, though
toilet training-wasn’t a problem. The mother’s frequent depressions may have
contributed to these difficulties along with his father’s authoritarianism. Mrs. Q.’s
depressions continued to the phallic-oedipal stage and we may assume P. felt he could
have given her more suppoil and protection than his father did. The mother’s suicide at
the beginning of his latency caused an upset in this relatively peaceful period and sent
P. back to using the
Clinical Examples 167
defenses of an earlier developmental level and caused a hiatus in further growth.
Latency was accomplished, as seen in his adequate move from play to work, but the
damage was there, P. recalls that his repetitions began at about eight or nine years of
age, soon after mother’s death and his father’s remarriage. The suppression of
information about his mother and the birth of another child served to reinforce P.’s
feeling of being.
left out and unncessary.
The threatening arrival of adolescence was probably the last straw in P.’s ability to
ward off the instinctual impulses and oedipal conflicts tha t we r e then r e ignit ed.
•
P, is now beginning to feel that he needs his father less than before and this can be
seen as a sign of the impending move into adolescence. P. finds this very upsetting
however, because of his paradoxical view of loving and hating his “all-powerful”
father.
Assessment of Fixation Points and Regressions
There is a fixation to the anal-sadistic and phallic-oedipal stages, with defenses
against regression to oral wishes and fantasies, This can be seen in his obsessive
compulsi-ve behavior and need to re-enact the oedipal situation. There are also some
elements of regression to oral sadism as exemplified in his food rituals.
Assessment of Conflicts
P.’s conflicts have an internal and internalized nature. The internal conflicts are:
(1) general ambivalence—his decision making is tortured, as when he wanted to give
his stepmother a Mother’s Day present but felt to do so might make her unhappy, even
though he also thought it might make her happy; (2) masculinity vs. femininity; and
(3) sadism vs. Masochism.
The internalized conflicts reflect the internalization of previously external conflicts.
There are regressive traces of the oral, anal and phallic-oedipal phases: (1) oral: eating
difficulties previously mentioned; (2) anal: reflected in his fears of aggression, death,
and his reference to death wishes, concerns with germs and magic; (3) phallic-oedipal:
as seen in his crushes and wish to re-enact the oedipal triangle.
168 Obsessional Neuroses
The latter is expressed in jealousy of his therapist and a female ward staff whenever
separations are imminent or when they are observed by P. to be interacting with male
staff. P. is also expressing some concern that his problems will make his therapist
depressed, necessitating her treatment as an inpatient at N. P. I. There is an obvious
sadistic wish here since he is angry about her impending vacation but there is also
guilt .perhaps reminiscent of the guilt he felt for not “making his mother happy” and
thus preventing her depreisions and subsequent suicide, for which he no doubt feels
responsible.
Assessment of Some General Characteristics
Frustration tolerance: 1
3
,
1s frustration tolerance is poor because of the pervasive
nature of his obsessions and compulsions. He feels he must do his repetitions even
though they take up a lot of time, If he is pushed beyond his own limit he will cry and
become very stubborn and accuse people of not understanding him or his problem.
Attitude toward anxiety: P. is engaged in a constant struggle to avoid anxiety. The
defenses he uses create the illusion of power and control and temporarily reduce_
anxiety.
At present, P.’s anxieties are so severe that he invests more and more time in
warding them off. His obsessive rituals consume most of his time and overshadow all
other events in his life. Despite their initial intensity they became worse during a
period when P. began to ask questions about his mother and to criticize his father’s
handling of her death. After this the obsession took on a more magical representation
(voodoo), attempting to hide the death wish he felt toward his father.
Sublimation potential: In view of the -present behavior crisis it is difficult to judge
the true sublimation potential, One can assume that it is quite high judging by his
latency-age creativity. For example, P. is making a report on the state of Israel,-This
reflects his search for an identity and his questioning about his mother. However this
has been interfered with and is now a problem for P. He may substitute.the study of
Saudi Arabia because he ‘feels that –
too many magical events happened in the creation
of the state of Israel, that the number 13 appears very often in its history. The one
example he uses is that Israel
Clinical. Examples 169 .
was formed on 13 May 1948; Robert was born on the 13th of the month and his mother
died on the 13th of the month.
Progressive vs. regressive tendencies: P. has a tremendous desire to move forward
and be rid of his problem. He has the potential for progressive movement. He also
acknowledges a disbelief that he will ever be without it or that certain areas of conflict
will cease to concern him. There is also an element of fear of what would happen if he
were no longer obsessive.
He wants to become an adolescent, mature, date, marry, go to medical school but all of
these things pose the threat of failure or worse, success (outdoing father). Sometimes P.
regresses, especially in O.T. groups when he is with younger children. Fear of a
classmate and separation from a teacher several weeks ago prompted P.’s need for a
transitional object, a small clay rabbit which he had made in 0.T. was carried to school
and brought to therapy.
Diagnosis
There are a cornbination of permanent regressions which cause extraordinary
developmental Strain, and crippling symptom formation according to the location of the
fixation point and the amount of ego superego involvement. The symptomatic picture is
that of an obsessive compulsive neurosis.
