Obsessive-compulsive Disorder
In obsessive-compulsive disorder (OCD), patients with what has been called “health anxiety” may become overwhelmed with the responsibility to keep themselves or loved ones healthy. These people are often mistakenly called “germophobic,” although this is actually OCD rather than a simple phobia. In this case, the patient tries to avoid all possible contaminants, exposure to germs, and people who might be ill. These are the people who develop washing and cleaning compulsions, who use paper towels to open restroom doors and won’t sit down on toilets, who avoid friends with colds, who carry around antibacterial wipes and lotions, and who keep their children from touching railings in public places. These are the people who see the world as full of danger to their health: they avidly follow the news of possible toxic substances such as outgassing furniture and X-ray dangers in airports. They are likely to eat only organic foods. They worry about and try to avoid anything that has the slightest chance of causing illness. Even when the science is poor and the sources of information are questionable or incorrect (i.e., the dangers of childhood vaccinations), these patients prefer avoidance to taking any risks with health issues. They are often phobic of medication side effects. They may see themselves as living a holistic or natural lifestyle, but beneath the surface is the larger problem of being unable to assess health risks rationally. They might find themselves cleaning the kitchen for a second time after having had a “doubt” about whether or not the sponge itself was clean enough; they might be stuck in the bathroom washing themselves; they develop food allergy fears and food avoidances because they had a mildly runny nose after a meal; they don’t shake hands because it is unsanitary. This is about preventing illness and the impossible quest of being certain that one has done everything possible to protect one’s own and loved ones’ health.
Hypochondria
In hypochondria, the issue is a conviction that one is or might be ill, and there is an endless search to affirm, diagnose, and treat that illness. Intolerance of uncertainty is the issue here. People say things like “I would rather know I have cancer than be told I might have cancer.” These patients are vigilantly looking for signs and symptoms of illness: “Can this spot be cancer?”, “Does this funny sensation in my chest indicate heart disease?”, “Is this a lump that needs to be biopsied?” They often check their blood pressure and pulse regularly; they ask for blood and imaging tests frequently; they check the internet on multiple sites about a variety of illnesses no matter how esoteric; they bring articles from magazines and websites to their doctors; they join online support groups of patients with questionable conditions; they own their own medical books. Frequently the sensations they have are quite real but the error is in thinking they are important. For example, everyone has minor aches and pains which, if left to benign neglect, go away on their own or wax and wane with the passage of time. They are not indications of a more serious problem. Sometimes there are sensory obsessions (“Do I have too much or too little saliva?”, “Does my swallowing feel right?”, “Is my erection weaker?”). The illusion here is that checking will eventually provide an answer to settle the question and remove uncertainty. In fact, checking invariably raises new questions, and works only very temporarily to provide any relief. And, of course, it is possible for one to be both hypochondriacal and also actually sick.
Scrupulosity (Religious and Secular)
The Catholic Church has recognized scrupulosity (Abata, 1976) for centuries. It is a form of excessive religious observance that is pathological and destructive, and is based on a fundamental misunderstanding of what religious practice is intended to be (Ciarrocchi, 1995). Scrupulosity is a form of OCD that is expressed in religious or secular versions (often described as “overblown conscience”). The sufferer becomes obsessed with unanswerable questions about life, death, God, morality, right and wrong, and trying to be a “good person.” This is filtered through a perfectionistic, thought–action fusion, all-or-nothing context in which being good is never being good enough, being holy is never perfectly holy, being observant is not being done with the right thoughts and feelings, and altruism is impossible because it gives pleasure. There is a frightening and hopeless quest for certainty about going to heaven rather than hell, or pleasing God, or never harming another soul—even inadvertently—that dominates their life and overwhelms the patient. People with scrupulosity are horrified by uncertainty about their own motives, beliefs, and actions. They may be stuck in praying compulsions, frozen in place by unwillingness to inadvertently do something bad or wrong. They may ask a thousand questions that sound philosophical but are actually a compulsive attempt to “nail down the answers” to inherently complex and unanswerable questions. Examples of secular scrupulosity include (1) the patient who must travel back throughout his day to every place he visited to find out where to return the pencil he accidentally stole, (2) the patient who spends many hours each day looking for homeless people to give money, and is constantly haunted by thoughts that he did not give enough and he might have missed someone, (3) the patient who cannot say no to anyone who makes any request because it would be wrong to refuse a favor if it is within her power to grant it.
Religious scrupulosity is not just profound religion. It is an obsessive-compulsive distortion of religious teachings. It gives none of the peace and joy that true religious observance provides. It is not about following a good life guided by good values. People with scrupulosity do not feel closer to God, they are constantly questioning whether they have displeased, disobeyed, or become alienated from God. Treatment may need to involve a well-informed member of the clergy to help the patient see the difference between scrupulosity and true religion. Interestingly, more and more clergy are becoming aware of this issue, and make appropriate referrals to treatment specialists.
Religious scrupulosity is not just profound religion. It is an OCD distortion of religious teachings and gives none of the peace and joy that true religious observance provides.
Emetophobia (Fear of Vomiting)
Emetophobia (Boschen, 2007) is the term given to fear of vomiting. While it would appear on the surface to be a relatively straightforward specific phobia, in reality this is not the case. Fear of vomiting can result from a number of different underlying fears: for some, the loss of control—and the physical sensations of vomiting—provides the horror. For others, the fears are primarily in the interpersonal sphere and involve humiliation and enduring the disgust or pity of others. For some there are intrusive memories of traumatic experiences involving vomiting or feelings of nausea. While early sexual abuse has been reported, data suggest it is much more common to have been raised by an anxious parent who was also afraid of vomiting (Christie, 2011). For others, there are no memories in particular, and there may not have been an actual episode of vomiting for many, many years. A great many of these people avoid crowds, friends, or family who might be sick, avoid shaking hands, and can look very much like health anxiety sufferers. Others simply become panicky when they themselves feel nausea or have anticipatory anxiety with vague gastrointestinal sensations. Female sufferers often put off having children because of the fear of morning sickness.
Treating emetophobia effectively requires an exposure-based regimen with considerable repetition—and a willingness on the part of the patient to risk nausea and possibly vomiting along the way. Deliberately inducing vomiting by using ipecac has been suggested by some but is definitely not recommended, and can be a dangerous route. In fact, it is far more important to experience the risk of possibly vomiting than vomiting itself, and learn how to tolerate this risk, rather than force vomiting in the hope of making it less awful. Motivational discussion (“what do you have to pay in order to not confront your fear?”) may need to be revisited often. Creative exposure tasks include a wide variety of YouTube videos, as well as making or purchasing and smelling fake vomit (there are some recipes involving over-ripe cheese that are readily available online). For those with interpersonally oriente
d fears, exposure tasks might involve going into a public bathroom stall and making vomiting noises when someone else is on the bathroom, as just one example.
Emetophobics need to experience the risk of possibly vomiting more than vomiting itself.
Paruresis (Shy Bladder Syndrome)
Shy bladder syndrome is defined as the inability to urinate in situations where one might be seen or heard doing so. It occurs in both men and women, but it is far more prevalent in men, likely due—at least to some extent—to the way public bathrooms in western cultures are designed and the differences in male and female anatomy. People with paruresis are not afraid of public bathrooms, they simply cannot use them. The requisite relaxation of musculature required to urinate does not occur. This sets up significant avoidance behaviors and anticipatory anxiety surrounding activities with no accessible “safe” bathrooms. Trying harder to let go results in the paradoxical exacerbation of the problem (Soifer, Zgourides, Himle, and Pickerling, 2001).
Paruresis can be mild—and handled with such “coping skills” as minor fluid restriction, using stalls instead of urinals and what we classify as avoidances—e.g., going home from work at lunchtime to urinate. Or it can be severely debilitating, resulting in highly restricted lives verging on being housebound. People with paruresis cannot take jobs where there is urine testing as part of the application process. They suffer agonies in the military, prisons, and boarding schools. Long airplane flights are sometimes impossible. Paruresis is usually accompanied by feelings of shame and secrecy, and patients may avoid dating and telling family members about their problem and why they are avoiding certain activities. Some have taught themselves how to self-catheterize to forestall medically dangerous situations. Until recently, most with shy bladder believed they were the only ones with such a problem. Fortunately, the IPA (International Paruresis Association) has a presence on the internet and is dedicated
Paruresis can be severely debilitating.
to disseminating the latest information available about research, advocacy, and treatment options, the most effective of which is specialized cognitive behavior therapy.
Currently, shy bladder syndrome is classified as a social anxiety disorder. It is common that people with paruresis do have a searing memory of a traumatic incident involving urination, and most frequently the disorder begins during the childhood or teenage years. Sometimes there are other aspects of social anxiety, but frequently the symptoms of the disorder stand alone. The exact physiological mechanisms involved in the disorder are not well understood.
Note
1. The Anxiety and Depression Association of America (ADAA) produced a white paper on GAD (ADAA White Paper (2004) Improving the Diagnosis and Treatment of Generalized Anxiety Disorder: A Dialogue between Mental Health Professionals and Primary Care Physicians—Produced by Anxiety Disorders Association of America, retrieved from www.adaa.org/sites/default/files/FinalADAGADPaper.pdf) with the recommendation that anxiety not be listed as a “rule out” diagnosis. That is, the recommendation was to change the current protocol of first investigating physical reasons for symptoms, and coming to the diagnosis of anxiety disorder only when every other cause is ruled out. The ADAA recommended that anxiety be ascertained in the same manner as other presenting problems.
References
Abata, R. M. (1976) Helps for the scrupulous. Liguori, MO: Liguori Publications.
Ciarrocchi, J. W. (1995) The doubting disease: Help for scrupulosity and religious compulsions. Mahwah, NJ: Paulist Press.
Boschen, M. J. (2007) Reconceptualizing emetophobia: A cognitive–behavioral formulation and research agenda Journal of Anxiety Disorders 21(3) 407–419.
Christie, A. (2011) Emetophobia: Fear of Vomiting. Information for Professionals, Sufferers and their Families. Emetophobiahelp.org. Retrieved from www.emetophobiahelp.org/fact-sheet.html
Soifer, S., Zgourides, G. D., Himle, J., and Pickerling, N.L. (2001) Shy bladder syndrome: Your step-by-step guide to overcoming paruresis. Oakland, CA: New Harbinger.
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Relapse Prevention
This chapter focuses on steps to ensure that recovery is enduring and that patients walk away from regular therapy appointments with what they need. We again address our definition of recovery, and the preventive work that should be done to identify leftover avoidance behaviors which can undermine the positive effects of treatment. Finally we answer the questions about the roles of exploratory psychotherapy and stress management.
Anxiety Disorders Are Chronic Intermittent Disorders: They Come Back
Unless a person lives an unrealistically limited life in which no physical or emotional stressors occur—as well as any excitement or novelty or challenges or boredom—it is highly likely that symptoms of anxious arousal will recur at some point. Sometimes that is two weeks after stopping formal therapy, sometimes after two or even 20 years. When an intrusive unwanted bizarre thought or a whoosh of panic or an urge to avoid suddenly appears, it is most important that the patient be prepared for and even expect such an event. Otherwise, there may ensue terrible demoralization (“I thought I was better!”) or shame (“I guess I am just a loser”) or anger (“I was sold a bill of goods, this stuff does not work!”). This is why we talk about not “if” symptoms return, but “when,” and what to do and how to embrace it when that happens. This form of inoculation will be invaluable in the future.
We talk about not “if” but “when” symptoms come back, and what to do and how to embrace it when that happens.
We also look at relapse prevention as a lifestyle effort. It makes no sense at all for people to say “I have learned to exercise so being sedentary is no longer a problem for me,” unless they include what they learn into their day to day life. The same can be said with weight control. Knowing healthy eating has little benefit unless people integrate what they know into everyday life. This is especially relevant for people with a history of substance abuse. It accounts for the remarkable popularity—and relatively high success rates—of the 12-step method groups. If we take this argument to a more explicitly medical context, diabetes is a chronic disorder that requires lifestyle changes and ongoing maintenance and attention to delay the progression of associated medical issues.
Lifestyle change in the context of anxiety disorders does not mean to avoid stress: it means pay regular attention to those physical and emotional factors which tend to make one sensitized and vulnerable to setbacks and re-emergence of symptoms. However, even if one is diligent about lifestyle changes, there will be times when symptoms return and the attitude towards this occurrence will be of utmost importance, determining whether the return of symptoms is short-lived and simple—or plummets into relapse, avoidance behavior, and feelings of demoralization.
The Most Enduring Recovery Is When Symptoms Do Not Matter
There are two different kinds of “getting better” which are distinctly different in their resilience in the face of ongoing stressors. The first is a state of relief in which symptoms are “controlled” or “managed” or “limited” by expanded territorial boundaries, “coping skills,” subtle avoidance behaviors, or compromises and “settling” for some limitations. These are people who can go “anywhere” within the state now, but could not imagine taking a trip overseas, or people who can now touch the handles on the taps in a public toilet but could “never” touch the bottom of their shoes, or who can manage to speak at a small meeting at work but refuse promotions that involve public speaking because that would be too much. Often these incomplete recoveries are huge improvements in the lives of these patients—and frequently they want to stop when the essentials of their lives are do-able without significant distress. They are willing to forgo unessential challenges in order not to experience the dread and misery and self-doubts involved in expanding beyond their current limitations. They are so happy to be able to grocery shop on their own in the neighborhood that they cannot imagine why it is important to shop anywhere else. Even though they are afraid to ent
er the subway, there are buses and cars they can ride now, so why, they ask, should they even worry about the subway?
Anxiety “managed” or “controlled” is an incomplete recovery.
The answer is that, although their lives are much improved, what has happened is that they have gained confidence not in their ability to handle, live with, or embrace anxiety but only the confidence that anxiety is no longer likely to occur in that particular situation or circumstance. This kind of confidence is likely to shatter when anxiety does happen to occur in a previously deemed “safe” circumstance or while doing something previously mastered.
“Confidence” that anxiety won’t happen is shattered when it occurs in a previously “mastered” circumstance.
What is missing is that the relationship to anxiety itself has not changed. Anxiety is still dreaded and avoided and feared. Effort is still being expended in arranging circumstances to minimize anxiety and there is still a concept that there is something like “too much” anxiety or unacceptable levels of anxiety. In the long run, if the occurrence of anxiety symptoms is not acknowledged as one of the natural consequences of living in a human body with mental and physical manifestations of arousal, then the vulnerability to relapse is increased. If the attitudinal shift we have been addressing has not occurred—even if the patient is currently significantly less anxious—than the next time they are sensitized and an anxious symptom pops up, there will not be acceptance or curiosity, but fear.
What Every Therapist Needs to Know About Anxiety Disorders Page 31