David Barlow, the former head of the Center for Anxiety and Related Disorders, says the goal of exposure therapy is to “scare the hell out of the patient” in order to teach him that he can handle the fear. Barlow’s exposure techniques may sound cruel and unusual, but he claims a phobia cure rate of up to 85 percent (often within a week or less), and an ample number of studies support this claim.*
The idea behind Dr. M.’s notion of trying to combine my exposures to public speaking and to vomiting was to ratchet up my anxiety as high as possible—the better to “expose” me to it, and to the things that I feared, so that I could begin the process of “extinguishing” those fears. The problem was that these simulations were too artificial to generate the requisite level of anxiety in me. Speaking to a few graduate students in Dr. M.’s office made me nervous and uncomfortable, but it never generated anything like the all-consuming dread that a real public speaking engagement does—especially since I knew that the graduate students were all studying anxiety disorders. I didn’t feel compelled, as I usually do, to try to hide my anxiety; I already assumed Dr. M.’s colleagues saw me as damaged, and therefore I didn’t have to go to such anxiety-producing lengths to hide my damagedness. So although even small meetings at work could still throw me into an agony of panic—to say nothing of the large-scale public speaking engagements that I would dread for months in advance—the faux presentations I’d make in my weekly sessions with Dr. M. felt like clammy facsimiles of the real thing. Awkward and unpleasant, yes, but not sufficiently anxiety provoking to be effective exposure therapy.
Similarly, while the experience of watching the vomit videos was discomfiting and unpleasant, it produced nothing close to the level of limb-trembling, soul-shaking horror that feeling about to vomit does; I knew the videos couldn’t infect me, and I knew I could always simply look away, or turn them off, if my anxiety became too much to bear. Crucially—and fatally, as far as effective exposure therapy went—escape was always possible.†
Determining—as a number of other therapists, before and since, also have—that my fear of vomiting lay at the core of my other fears (for instance, I’m afraid of airplanes partly because I might get airsick), Dr. M. proposed that we concentrate on that.
“Makes sense to me,” I concurred.
“There’s only one way to do that properly,” she said. “You need to confront the phobia head-on, to expose yourself to that which you fear the most.”
Uh-oh.
“We have to make you throw up.”
No. No way. Absolutely not.
She explained that a colleague had just successfully treated an emetophobe by giving her ipecac syrup, which induces vomiting. The patient, a female executive who had flown in from New York to be treated, had spent a week visiting the Center for Anxiety and Related Disorders. Each day she’d take ipecac administered by a nurse, vomit, and then process the experience with the therapist—“decatastrophizing” it, as the cognitive-behavioral therapists say. After a week, she flew back to New York—cured, Dr. M. reported, of her phobia.
I remained skeptical. Dr. M. gave me an academic journal article reporting on a clinical case of emetophobia successfully treated with the ipecac exposure method.
“This is just a single case,” I said. “It’s from 1979.”
“There have been lots of others,” she said, and reminded me again of her colleague’s patient.
“I can’t do it.”
“You don’t have to do anything you don’t want to do,” Dr. M. said. “I’ll never force you to do anything. But the only way to overcome this phobia is to confront it. And the only way to confront it is to throw up.”
We had many versions of this conversation over the course of several months. I trusted Dr. M. despite the inane-seeming exposures she cooked up for me. (She was kind and pretty and smart.) So one autumn day I surprised her by saying I was open to thinking about the idea. Gently, reassuringly, she talked me through how the process would work. She and the staff nurse would reserve a lab upstairs for my privacy and would be with me the whole time. I’d eat something, take the ipecac, and vomit in short order (and I would survive just fine, she said). Then we would work on “reframing my cognitions” about throwing up. I’d learn that it wasn’t something to be terrified of, and I’d be liberated.
She took me upstairs to meet the nurse. Nurse R. showed me the lab and told me that taking ipecac was a standard form of exposure therapy; she said she’d helped preside over a number of exposures for erstwhile emetophobes. “Just the other week, we had a guy in here,” she said. “He was very nervous, but it worked out just fine.”
We went back downstairs to Dr. M.’s office.
“Okay,” I said. “I’ll do it. Maybe.”
Over the next few weeks, we’d keep scheduling the exposure—and then I’d show up on the appointed day and demur, saying I couldn’t go through with it. I did this enough times that I shocked Dr. M. when, on an unseasonably warm Thursday in early December, I presented myself at her office for my regular appointment and said, “Okay. I’m ready.”
The exercise was star-crossed from the beginning. Nurse R. was out of ipecac, so she had to run to the pharmacy to get some more while I waited for an hour in Dr. M.’s office. Then it turned out that the upstairs lab was booked, so the exposure would have to take place in a small public restroom in the basement. I was constantly on the verge of backing out; probably the only reason I didn’t was that I knew I could.
What follows is an edited excerpt drawn from the dispassionate-as-possible account I wrote up afterward on Dr. M.’s recommendation. (Writing an emotionally neutral account is a commonly prescribed way of trying to forestall post-traumatic stress disorder after a traumatic experience.) If you’re emetophobic yourself, or even just a little squeamish, you might want to skip over it.
We met up with Nurse R. in the basement restroom. After some discussion, I took the ipecac.
Having passed the point of no return, I felt my anxiety surge considerably. I began to shake a little. Still, I was hopeful that sickness would strike quickly and be over fast and that I would discover the experience was not as bad as I’d feared.
Dr. M. had attached a pulse and oxygen-level monitor to my finger. As we waited for the nausea to hit, she asked me to state my anxiety level on a scale of 1 to 10. “About a nine,” I said.
By now I was starting to feel a little nauseated. Suddenly I was struck by heaving and I turned to the toilet. I retched twice—but nothing felt like it was coming up. I knelt on the floor and waited, still hoping the event would come quickly and then be over with. The monitor on my finger felt like an encumbrance, so I took it off.
After a time, I heaved again, my diaphragm convulsing. Nurse R. explained that dry-heaving precedes the main event. I was now desperate for this to be over.
The nausea began coming in intense waves, crashing over me and then receding. I kept feeling like I was going to vomit, but then I would heave noisily again and nothing would come up. Several times I could actually feel my stomach convulse. But I would heave and … nothing would happen.
My sense of time at this point gets blurry. During each bout of retching, I would begin perspiring profusely, and when the nausea would pass, I would be dripping with sweat. I felt faint, and I worried that I would pass out and vomit and aspirate and die. When I mentioned feeling light-headed, Nurse R. said that my color looked good. But I thought she and Dr. M. seemed slightly alarmed. This increased my anxiety—because if they were worried, then I should really be scared, I thought. (On the other hand, at some level I wanted to pass out, even if that meant dying.)
After about forty minutes and several more bouts of retching, Dr. M. and Nurse R. suggested I take more ipecac. But I feared a second dose would subject me to worse nausea for a longer period of time. I worried I might just keep dry-heaving for hours or days. At some point, I switched from hoping that I would vomit quickly and have the ordeal over with to thinking that maybe I could fight the ipecac a
nd simply wait for the nausea to wear off. I was exhausted, horribly nauseated, and utterly miserable. In between bouts of retching, I lay on the bathroom tiles, shaking.
A long period passed. Nurse R. and Dr. M. kept trying to convince me to take more ipecac, but by now I just wanted to avoid vomiting. I hadn’t retched for a while, so I was surprised to be stricken by another bout of violent heaving. I could feel my stomach turning over, and I thought for sure that this time something would happen. It didn’t. I choked down some secondary waves, and then the nausea eased significantly. This was the point when I began to feel hopeful that I would manage to escape the ordeal without throwing up.
Nurse R. seemed angry. “Man, you have more control than anyone I’ve ever seen,” she said. (At one point, she asked peevishly if I was resisting because I wasn’t prepared to terminate treatment yet. Dr. M. interjected that this was clearly not the case—I’d taken the ipecac, for God’s sake.) Eventually—several hours had now elapsed since I ingested the ipecac—Nurse R. left, saying she had never seen someone take ipecac and not vomit.‡
After some more time passed, and some more encouragement from Dr. M. to try to “complete the exposure,” we decided to “end the attempt.” I still felt nauseated, but less so than before. We talked briefly in her office, and then I left.
Driving home, I became extremely anxious that I would vomit and crash. I waited at red lights in terror.
When I got home, I crawled into bed and slept for several hours. I felt better when I woke up; the nausea was gone. But that night I had recurring nightmares of retching in the bathroom in the basement of the center.
The next morning I managed to get to work for a meeting—but then panic surged and I had to go home. For the next several days, I was too anxious to leave the house.
Dr. M. called the next day to make sure I was okay. She clearly felt bad about having subjected me to such a miserable experience. Though I was traumatized by the whole episode, her sense of guilt was so palpable that I felt sympathetic toward her. At the end of the account I composed at her request, which was accurate as far as it went, I masked the emotional reality of what I thought (which was that the exposure had been an abject disaster and that Nurse R. was a fatuous bitch) with an antiseptic clinical tone. “Given my history, I was brave to take the ipecac,” I wrote. “I wish that I had vomited quickly. But the whole experience was traumatic, and my general anxiety levels—and my phobia of vomiting—are more intense than they were before the exposure. I also, however, recognize that, based on this experience in resisting the effects of the ipecac, my power to prevent myself from vomiting is quite strong.”
Stronger, it seems, than Dr. M.’s. She told me she had to cancel all of her afternoon appointments on the day of the exposure—watching me gagging and fighting with the ipecac evidently had made her so nauseated that she spent the afternoon at home, throwing up. I confess I took some perverse pleasure from the irony here—the ipecac I took made someone else vomit—but mainly I felt traumatized and intensely anxious. It seems I’m not very good at getting over my phobias but quite good at making my therapists and their associates sick.
I continued seeing Dr. M. for a few more months—we “processed” the botched exposure and then, both of us wanting to forget the whole thing, turned from emetophobia to various other phobias and neuroses—but the sessions now had an elegiac, desultory feel. We both knew it was over.§
That sphincter which serves to discharge our stomachs has dilations and contractions proper to itself, independent of our wishes, and even opposed to them.
—MICHEL DE MONTAIGNE,
“ON THE POWER OF THE IMAGINATION” (1574)
The mind, as the neurophilosophers say, is fully embodied; it is, as Aristotle put it, “enmattered.” The bodily clichés of nervous excitement (“butterflies in the stomach”), anxious anticipation (“a loosening of the bowels,” “scared shitless”), or dread (felt “in the pit of the stomach”) are not in fact clichés or even metaphors but truisms—accurate descriptions of the physiological correlates of anxious emotion. Doctors and philosophers have observed for millennia the potency of what the medical journals call the brain-gut axis. “There may even be some connection between a phobia and a beef-steak, so intimately related are the stomach and the brain,” Wilfred Northfield wrote in 1934.
Nerve-disordered bellies are a bane of modern existence. According to a Harvard Medical School report, as many as 12 percent of all patient visits to primary care physicians in the United States are for irritable bowel syndrome, or IBS, a condition characterized by stomach pain and alternating bouts of constipation and diarrhea that most experts believe to be wholly or partly caused by stress or anxiety. First identified in 1830 by the British physician John Howship, IBS has since then been referred to as “spastic colon,” “spastic bowel,” “colitis,” and “functional bowel disease,” among other names. (Physicians in the Middle Ages and Renaissance referred to it as “windy melancholy” and “hypochondriache flatulence.”) Because no one has ever definitively identified an organic cause of IBS, most doctors attribute its appearance to stress, emotional conflict, or some other psychological source. In the absence of a clear malfunction in the nerves and muscles of the gut, doctors tend to assume a malfunction in the brain—perhaps a hypersensitized awareness of sensations in the intestine. In one well-known set of experiments, when balloons were inflated in the colons of both IBS patients and healthy control subjects, the IBS patients reported a much lower threshold for pain, suggesting that the viscera–brain connection may be more sensitive in patients with irritable bowels.
This is consistent with a trait called anxiety sensitivity, which research has shown to be strongly correlated with panic disorder. Individuals who rate high on the so-called Anxiety Sensitivity Index, or ASI, have a high degree of what’s known as interoceptive awareness, meaning they are highly attuned to the inner workings of their bodies, to the beepings and bleatings, the blips and burps, of their physiologies; they are more conscious of their heart rate, blood pressure, body temperature, breathing rates, digestive burblings, and so forth than other people are. This hyperawareness of physiological activity makes such people more prone to “internally cued panic attacks”: the individual with a high ASI rating picks up on a subtle increase in heart rate or a slight sensation of dizziness or a vague, unidentifiable fluttering in the chest; this perception, in turn, produces a frisson of conscious anxiety (Am I having a heart attack?), which causes those physical sensations to intensify. The individual immediately perceives this intensification of sensation—which in turn generates more anxiety, which produces still more intensified sensations, and before long the individual is in the throes of panic. A number of recent studies published in periodicals like the Journal of Psychosomatic Research have found a powerful interrelationship among anxiety sensitivity, irritable bowel syndrome, worry, and a personality trait known as neuroticism, which psychologists define as you would expect—a tendency to dwell on the negative; a high susceptibility to excessive feelings of anxiety, guilt, and depression; and a predisposition to overreact to minor stress. Unsurprisingly, people who score high on cognitive measures of neuroticism are disproportionately prone to developing phobias, panic disorder, and depression. (People who score low on the neuroticism scale are disproportionately resistant to those disorders.)
Evidence suggests that people with irritable bowels have bodies that are more physically reactive to stress. I recently came across an article in the medical journal Gut that explained the circular relationship between cognition (your conscious thought) and physiological correlates (what your body does in response to that thought): people who are less anxious tend to have minds that don’t overreact to stress and bodies that don’t overreact to stress when their minds experience it, while clinically anxious people tend to have sensitive minds in sensitive bodies—small amounts of stress set them to worrying, and small amounts of worrying set their bodies to malfunctioning. People with nervous stomachs are
also more likely than people with settled stomachs to complain of headaches, palpitations, shortness of breath, and general fatigue. Some evidence suggests that people with irritable bowel syndrome have greater sensitivity to pain, are more likely to complain about minor ailments like colds, and are more likely to consider themselves sick than other people.
Most cases of stomach upset, the physiologist Walter Cannon wrote back in 1909, are “nervous in origin.” In his article “The Influence of Emotional States on the Functions of the Alimentary Canal,” Cannon concluded that anxious thoughts had direct effects—through the nerves of the sympathetic nervous system—on both the physical movements of the stomach (that is, on peristalsis, the process by which the digestive system moves food through the alimentary canal) and gastric secretions. Cannon’s theory has been borne out by modern surveys conducted at primary care centers, which find that most routine stomach trouble emanates from mental distress: between 42 and 61 percent of all patients with functional bowel disorders have also been given an official psychiatric diagnosis, most often anxiety or depression; one study has found a 40 percent overlap between patients with panic disorder and functional GI disease.‖
“Fear brings about diarrhea,” Aristotle wrote, “because the emotion causes an augmenting of heat in the belly.” Hippocrates attributed both bowel trouble and anxiety (not to mention hemorrhoids and acne) to a surplus of black bile. Galen, the ancient Roman physician, blamed yellow bile. “People attacked by fear experience no slight inflow of yellow bile into the stomach,” he observed, “which makes them feel a gnawing sensation, and they do not cease feeling both distress of mind and the gnawing until they have vomited up the bile.”
But it was only in 1833, with the publication of a monograph called Experiments and Observations on the Gastric Juice and the Physiology of Digestion, that the link between emotional states and indigestion began to be understood with any kind of scientific precision. On June 6, 1822, Alexis St. Martin, a hunter employed by the American Fur Company, was accidentally shot in the stomach at close range by a musket loaded with buck shot. He was expected to die—but under the care of William Beaumont, a physician in upstate New York, he survived, albeit with an unusual condition: an unhealed open hole, or fistula, in his stomach. Beaumont realized that the hunter’s fistula provided a remarkable opportunity for scientific observation: he could literally see into St. Martin’s stomach. Over the next decade, Beaumont conducted many experiments using the hunter’s fistula as a window into his digestive workings.
My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind Page 9