Ann, a 32-year-old medical secretary in Dublin, Ireland, is referred to a clinic for treatment of depression. She confides that the reason she is depressed is that for the last 5 months, she has been afraid that she will urinate in public. She has never actually done this, and in the safety of her own home, she considers the idea that it will actually happen to her to be nonsensical. When Ann is away from home, the fear dominates her thinking and she takes precautions to prevent this from happening. She always wears sanitary napkins, never travels far from home, limits her intake of fluids, has stopped drinking alcohol, and has had her desk at work relocated near a toilet. For the 2 weeks before the consultation, she was unable to go to work because the fear had become so intense. Ann vaguely recalls that her deceased father also had a fear of urinating in public. Before leaving for work each day, he urinated several times and avoided taking any fluids. Her younger sister has been successfully treated for a cleansing ritual. Ann had psychiatric treatment 10 years ago when she began to fear that she had contracted syphilis, even though there were no clinical or laboratory evidence of infection. Up until 5 months ago, she had never feared that she would urinate in public. In addition to these specific fears, she has always been an anxious, insecure person, considered by her family to be overly cautious and perfectionistic. For the past year, she has been upset about her boyfriend's impending return to his home country after completing his medical studies in Ireland. She was divorced 5 years previously and is now living with her 7-year-old son and mother. Her mother disapproves of her boyfriend, and Ann has felt increasing pressure to end the relationship. She believes that the onset of her current difficulties coincided with the stress of her relationship with her mother and the threat of her boyfriend's departure from the country. When interviewed, Ann is visibly anxious. She remarks that she has been feeling despondent about her problems. She has trouble sleeping and has no energy during the day. Although her appetite is poor, she has not lost any weight.