Ted: Clinical Case Study
Ted is a thirteen-year-old referred to a Midwestern inpatient psychiatric research ward because
of “senseless rituals and attention to minutiae.” He can spend three hours “centering” the toilet
paper roll on its holder or rearranging his bed and other objects in his room. When placing
down objects such as books or shoelaces after tying them, he picks them up and replaces them
several times until they seem “straight.” Although usually placid, he becomes abusive with
family members who try to enter his room for fear they will move or break his objects. When he
is at school, he worries that people may disturb his room. He sometimes has to be forced to
interrupt his routine to attend meals. Last year he hid pieces of his clothing around the house
because they wouldn’t lie straight in his drawers. Moreover, he often repeats to himself, ‘this is
perfect; you are perfect.” He makes a gesture of head bowing, hand saluting, and sniffing. When
outside, as in a movie house, he points his gestures in the direction of the house. To him, the
gesture is a form of tribute to the “perfection” of his room. It’s like “letting me know the room is
straight.”
There is a little other thought activity during his compulsive behavior. His attitude and
resistance fluctuate; he knows it takes time from his other interest-film making and projecting.
He can get through his rituals quickly if he wants to do something else; otherwise, he is quite
slow about them. He has little interest in school or socializing, and he doesn’t appear overly
concerned about his condition. Because he spends the whole day in compulsive arranging and
gesturing, he has not been able to attend school and is being tutored at home by his father.
Until he started kindergarten, his parents saw him as an average child who was cheerful and
outgoing. His early development had been normal except for head banging as a toddler. Upon
entering school, however, his teachers saw him as “withdrawn.” He could not tolerate contact
sports or anyone touching him. He was also quite apathetic, just “sitting there.” He always had a
fear of water, in spite of the fact that no untoward incident had ever occurred. He could not go
any further than ankle deep without panicking and protesting strongly and could only dangle his
feet over the edge of a pool.
At ten he also began fearing contamination from germs. He needed to know who had prepared
his food before eating. He picked up his food with paper if his hands were not washed and
placed the last piece of food back, fearing it was “drugged.” At eleven he began to wear two
layers of clothing, even in sweltering heat, so he would avoid “catching pneumonia” The teacher
was disturbed because he spent too much time washing his lips and mouth with his own
smuggled-in mouthwash and soap. Again, he feared germs were entering his mouth. On
reflection, he always acknowledged that these habits and thoughts were unreasonable.
Periodically, he could also go without taking a bath for many days for many days unless his
parents forced him. He kept the same clothes on, slept in his socks, stayed in his pajamas all
day, and neglected his chores unless great pressure was exerted on him.
Throughout grade school he remind aloof from other children. Although his parents sensed he
had affection for them, he never overtly expressed it. He would kiss his parents in a polite way
when he had to leave them. When Ted was eleven the family spent two years in a biweekly
family therapy with a psychologist, with no discernible effect. School officials became
progressively concerned about skin irritation and chapping from his cleansing ritual;
hospitalization was suggested at age twelve because he spent all his free time doing his rituals.