The Trainee Who Cannot Stop Checking
A 27-year-old junior bank officer is referred by his branch manager. For 14 months he has checked the gas knobs at home exactly 12 times before leaving, and re-read each email draft 8-10 times before sending. He arrives 40 minutes early to re-verify his cash drawer, and has twice been late to client meetings. He describes intrusive thoughts that a mistake will cause a family fire or a client's ruin, and says the checking 'buys about ten minutes of calm.' He sleeps 5 hours, has dropped his gym routine, and drinks 3 cups of coffee before work. He denies low mood, denies any history of mania, and scores 19 on the Yale-Brown Obsessive Compulsive Scale. He asks whether he simply needs 'better discipline' and whether medication will 'change his personality.' He has no suicidal ideation.
1. Using a functional-analysis framework, explain how the checking behaviour is being maintained, and identify what a behavioural formulation would predict about the effect of the branch manager's suggested 'just stop checking and be disciplined' instruction.
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Maintaining contingency (two-factor logic). The intrusive thought ('a mistake will cause fire/ruin') functions as a conditioned anxiety cue. Checking removes that cue and the anxiety drops within minutes. That relief is a negative reinforcement of checking, so the probability of checking rises. Because the relief is brief (about ten minutes, by his own report), the anxiety re-conditions and the cycle resets - a short-lived reinforcer that produces a high, rigid rate of behaviour.
Why the count is 12 and not 1. The fixed counts (12 knobs, 8-10 email re-reads) are not random; they are ritualised rules that themselves become discriminative stimuli ('not yet safe until the count is complete'). This is why the behaviour is slow, effortful, and eats into punctuality.
Prediction if he simply 'stops'. Sudden suppression without an alternative response will predictably produce a sharp rise in anxiety, an increase in intrusive thoughts (a rebound effect), and likely covert substitution - mental re-checking, reassurance-seeking from colleagues, or photographing the knobs. The manager's instruction also adds shame and secrecy, which reduces disclosure and increases risk. The formulation therefore predicts worsening, not improvement, and argues for exposure with response prevention, not willpower.
Contributing load. 5 hours' sleep and 3 coffees raise baseline arousal, lowering the threshold at which the intrusive thought triggers anxiety. Sleep and caffeine are modifiable and should be addressed alongside the exposure work.
2. The client asks whether medication will 'change his personality.' Draft a response that is accurate about likely mechanisms, distinguishes trait from symptom, and states what would need monitoring during a trial.
Read the worked answer
Frame the distinction first. Personality traits - his conscientiousness, his caution, his loyalty to clients - are stable dispositions. Symptoms are the repetitive checking and the intrusive doubt. The aim of treatment is to lower the symptom load so the traits can operate without the ritual. A useful line: 'The treatment targets the alarm system, not the person who set it.'
Mechanism, stated honestly. Serotonergic medication (for example an SSRI such as fluvoxamine or sertraline) is thought to dampen the loop between threat detection and the compulsion to neutralise it. It typically takes 4-8 weeks for meaningful change, and doses used in OCD are often higher and slower to escalate than in depression. It is not a sedative and does not erase caution. It is also not curative alone: guidelines place exposure and response prevention as the core psychological treatment, with medication as an adjunct for moderate-to-severe cases such as his (YBOCS 19 is in the moderate range).
What to monitor. Early transient nausea, headache, and sleep change; activation or restlessness in the first two weeks; any emergence of suicidal ideation (ask directly at each review); sexual side effects, which are a common cause of silent non-adherence; and, if a trial is stopped, a taper rather than abrupt cessation. Track YBOCS at baseline, 4 weeks, and 8-12 weeks so the decision is data-based rather than impression-based. Also flag the caffeine and sleep issue as a confound when judging early response.