Joe developed many rituals, as he became more and more ill. It was as if he was frightened that if he didn't carry out his daily rituals something terrible would happen. These are some of the rituals he developed:

• counting on his fingers throughout the day

• touching walls and surfaces as he walked around the house

• chewing his knuckles until they bled

• touching and/or walking around dustbins in the town and park

• picking up other people's litter, however disgusting it might be

• obsessive hand washing throughout the day

• strict routine of personal hygiene every evening at the same time

• keeping his bedroom spotless

• reading his children's bible out loud

• tracing the lines in his bible with his finger

• stepping over the room divides and cracks in the pavement

• shuffling up and down stairs one step at a time

• constant eye tic

• dragging one foot as he walked

• writing in a very flowery and elaborate manner.

When I asked him why he did these things he simply replied that it made him feel better. I wondered whether I should try and discourage Joe from doing them but concluded that they weren't doing Joe or anyone else any harm. I hoped that once he had regained weight he would lose the compulsion to do them and for the most part this happened very quickly. Six months after his discharge from the residential unit he was still touching surfaces, but all the other rituals had gone. I discussed this with Joe's psychiatrist who agreed it wasn't doing any harm. He advised me to keep an eye out for any other obsessive traits developing, but they never did. Soon after, Joe stopped touching surfaces of his own accord.

In most cases the development of ritualistic behaviour is directly related to weight loss and ongoing starvation. Whilst it might be distressing to watch it is often harmless. If any aspect of your son's behaviour is harmful in any way or upsetting for other family members then of course it should be discouraged. It might be useful to set boundaries for acceptable behaviour. For example, if your son is spending so much time in the bathroom in the morning that everyone else is late for school or work, then this behaviour is unacceptable. Rather than having a huge fight every day it is easier to give your son guidance as to what is acceptable. A gentle approach is likely to deliver the best outcome:

'I understand why you feel you need to spend more time in the bathroom at the moment, but other people need to use it as well. You can use the bathroom any time up until 7 am, but then it must be available for the rest of the family. I love you very much, but it is not acceptable that you are making everyone else late in the morning because you want to spend so long in the shower.'

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