Case 23: A man who is late for work because of how he dresses

Case 23: A man who is late for work because of how he dresses

A 42-year-old man, dismissed for coming late to work, who cannot get dressed without following a fixed sequence.

  • 2 min read
  • Checked 01 Nov 2026

The case

A 42-year-old man sees a psychiatrist after losing his job for arriving late again and again. Getting dressed in the morning takes him a long time, because he must follow a set order. If the order is broken, for instance if his left arm goes into a sleeve first, he takes everything off and starts again the "right" way: right arm first, then the left. At times he pictures himself being struck by a car in the street outside his office. To prevent it he has to say the word "safety" a hundred times, and when he is very tense, write it down. He sees that none of this is reasonable, yet he cannot set off for work until it is all done.

Summary

Diagnosis

Obsessive-compulsive disorder, or OCD.

What points to it

  • Obsessions: a need for things to be done in an exact order, and intrusive images of being hit by a car.
  • Compulsions: dressing in a fixed sequence and starting again when it is broken, repeating a word a hundred times, writing it down.
  • Insight and partial resistance: he knows the acts are senseless but cannot stop.
  • Obsessional slowness, which has cost him his job.

What else it could be

Anankastic personality disorder: lifelong perfectionism and rigidity that the person sees as reasonable, without intrusive thoughts resisted as senseless (the two can coexist). Tic disorders, which often come with OCD. The fixed routines of autism, which are wanted rather than resisted. A psychosis, if he believed the ritual truly prevents the accident and had no insight. Look too for depression, common after losing a job.

Management

  • Rate severity with the Y-BOCS, and repeat it to follow progress.
  • CBT with exposure and response prevention: he dresses in the "wrong" order, or holds back the word, and lets the anxiety settle without the ritual.
  • An SSRI, an antidepressant, often at higher doses, given at least 12 weeks and continued for at least a year after he is well.
  • Clomipramine if an SSRI fails, then specialist care.
  • Help with returning to work.

Outlook

Usually chronic, with fluctuations. Treatment reduces the symptoms in most people, but some remain, and they tend to worsen under stress.