paul salkovskis [email protected] institute of psychiatry centre for anxiety disorders and...
TRANSCRIPT
Paul [email protected]
Institute of Psychiatry Centre for Anxiety Disorders
and Trauma, Maudsley Hospital
What is toilet phobia? History, research and the present status of toilet phobia
TABOO
STIGMA
Toilet phobia: is it a distinct diagnosis?
What is the purpose of diagnosis?Does it tell us what the problem is?No, the person does that!Although it does not tell us what the
diagnosis is, it tells us where to begin to look
So…..should toilet phobia be a distinct diagnosis??
Toilet phobia:
Phobia: a clinical condition characterised by avoidance or by the person consistently experiencing fear when confronted by the feared object.
Other toilet fear: not being able to reach one in time (sometimes linked to Irritable bowel syndrome)
Use of toilet: unavoidable. Avoidance therefore tends to be of going out of
easy reach of a familiar “safe” toilet.
Psychological problems linked to toilet phobia
Specific phobia – toilet related stimuli– Claustrophobia
• Trapped • Suffocated
– Fear of being alone Agoraphobia, with and without panic Generalised Anxiety Disorder (GAD) Specific social phobia (“Social anxiety disorder”) Obsessive compulsive disorder (especially, but not only,
contamination fears) Paruresis Parcopresis
Special features
Stigma and taboosLink to primary bodily functions
Research
Epidemiology: very littleFundamental processess: social
psychology of paruresis. Little else. Treatment: patchy reportsNatural history:
– Some early onset, linked to childhood fears– Paruresis onset looks like social phobia
Physical findings: nothing consistent
What is toilet phobia?
A mixture of problems, with fears of toilets being the “final common pathway”
Anxiety and anxiety motivated safety seeking behaviour are the common features
Final common pathway of what?
What do we know about anxiety?
Normal emotionCan become a problem when it is severe
and persistent
perceived likelihood it will happen
Anxiety is proportional to the perception of danger; that is
Anxiety and threat: understanding the severity of anxietyAnxiety and threat: understanding the severity of anxiety
X
+
perceived“awfulness” if it did
perceived rescue factors
perceived coping abilitywhen it does
___________________________
negativeinterpretations
Events and situations
Reactions to perceived threat
Simplified Cognitive model of the persistence of anxiety
Anxiety: summary of cognitive-behavioural theoryAnxiety: summary of cognitive-behavioural theory
Anxiety is a result of perceived threatFactors which maintain exaggerated threat
beliefs will maintain anxietyResearch supports the hypothesis that these
factors include selective attention and other cognitive changes, mood changes, physiological reactions and safety seeking behaviours
Cognitive specificity in anxiety disordersCognitive specificity in anxiety disorders
Phobias: imminent danger from an identifiable situation Panic: imminent catastrophic danger indicated by bodily
sensations Hypochondriasis (health anxiety): less imminent
catastrophic danger indicated by medically relevant stimuli including bodily sensations
Social phobia: imminent negative social judgement Obsessive-compulsive disorder: responsibility for harm,
focussed on intrusive cognitions Generalised Anxiety Disorder: overestimation of threat,
intolerance of uncertainty, worry about worry
Beliefs in toilet phobia
I will be contaminated – That will be dangerous to me– That will be dangerous to others
I will panic and….(lose control, etc)I won’t be able to pee
negativeinterpretations
Events and situations
Automatic reactions
Simplified Cognitive model of the persistence of anxiety
Strategic reactions
Safety seeking behaviours in toilet phobia
Avoidance– General– Not going out– Choice of toilet, time of day, use of cubicles
Specific (subtle)– “In toilet behaviours”
WashingPrecautions to ensure proximity
Toilet phobia: is it a distinct diagnosis?
“Toilet phobia” is the manifestation of a range of different concerns focussed on toilets and the need to use the toilet.
Situation, not diagnosisWhy focus on it then?Psychological problems tend to be stigmatised In fears related to toilets and excretion, stigma is
complicated by taboos
Paul [email protected]
Institute of Psychiatry Centre for Anxiety Disorders
and Trauma, Maudsley Hospital
Obsessive compulsive disorder and toilet phobia
The Diagnostic phenomenology of OCD
Intrusive thoughts, images and impulsesObsessions and/or compulsionsCompulsions are meaningfully related to
fearsBy definition, the person seeks to ignore or
suppress intrusionsKey to diagnosis is distress/disability
Cognitive phenomenology of obsessions and compulsions
Obsession: A recurrent thought, image, impulse or doubt which creates awareness of the potential for danger which the person can cause or prevent
Compulsion: An action or reaction that is intended to both to prevent the danger of which the obsession has created awareness and to diminish responsibility for its ocurrence.
OCD and toilet fears
Fear of contamination of – Self– Others
Fear of losing control in public places
CBT for obsessional problems
Engagement in assessment: helping the patient to feel understood
Formulation: reaching a shared understandingDiscussion of alternative explanationsEngagement in treatment: helping the patient to
choose to changeHelping the patient to actively test the alternative
account and explore its implicationsGeneralising changesRelapse prevention
Treatment of OCD is highly successful
Cognitive behavioural therapyBut; availability still a problemFor some, engagement is an issueSolutions range from telephone therapy
(increased accessibility) to intensive treatment (for treatment refractory cases)
Paul [email protected]
Institute of Psychiatry Centre for Anxiety Disorders
and Trauma, Maudsley Hospital
Cognitive Behavioural Therapy and the treatment of toilet-related fears
“There is nothing as practical as a good theory”
Why do well validated theories result in better psychological treatments?
How psychological treatments workHow psychological treatments work
People suffer from anxiety because they think situations as more dangerous than they really are.
Treatment helps the person to consider alternative, less threatening explanations of their problem
If the alternative explanation is to be helpful:
It has to fit with your past experience It has to work when you test it out
Good therapy is about two (or more) people working together to find out how the world really works
What the patient usually What the patient usually wants and needs to knowwants and needs to know
Why is my anxiety so severe?Why does my anxiety persist?
Why me, why now?
perceived likelihood it will happen
Anxiety is proportional to the perception of danger; that is
Anxiety and threat: understanding the severity of anxietyAnxiety and threat: understanding the severity of anxiety
X
+
perceived“awfulness” if it did
perceived rescue factors
perceived coping abilitywhen it does
___________________________
negativeinterpretations
Events and situations
Reactions to perceived threat
Simplified Cognitive model of the persistence of anxiety
negativeinterpretations
Events and situations
Reactions to perceived threat
Persistence and origins of anxiety
Pre-existing assumptions
Anxiety: summary of cognitive-behavioural theoryAnxiety: summary of cognitive-behavioural theory
Anxiety is a result of perceived threatFactors which maintain exaggerated threat
beliefs will maintain anxietyResearch supports the hypothesis that these
factors include selective attention and other cognitive changes, mood changes, physiological reactions and safety seeking behaviours
Cognitive behavioural treatment
Engagement in assessment: helping the person to feel understood
Engagement in treatment: helping the person to commit themselves to the process of change
Formulation: reaching a shared understanding Discussion of alternative explanations Engagement in treatment: helping the patient to choose to
change Helping the patient to actively test the alternative account and
explore its implications Generalising changes Relapse prevention